♫KOCHAVIM 2012-2013♫
Come join our amazing youth choir and learn some of Jewish tradition’s greatest music!
Each evening will begin with a delicious pizza dinner followed by our rehearsal. Students will be provided with their own folder of music along with a list of performance dates and details. While this is an opportunity to have a fun time with friends and Cantor Natalie, Kochavim will be fulfilling the mitzvah of bringing joy and healing to our community through song.
Rehearsals: Wednesdays, beginning October, 2012 from 6:45-7:45pm
Cost:$50 per student (includes dinner and musical supplies)
Who:3rd Grade and up
Name(s) of Student(s): ______
Emergency Contact(s):
Name______Relationship______Phone #______
Name______Relationship______Phone #______
Emergency Information: In case of minor illness or injury of my children at school, I give the school staff permission to give basic first aid to my child. In case of a major injury or illness, I understand that staff will make every effort to contact me. If they are unable to do so, I give permission for my child’s physician and/or an ambulance to be contacted and for a physician to hospitalize and/or secure proper treatment for my child
1. Electronic Items: Ramat Shalom is not responsible for any phones or games brought to school. We therefore suggest that you do not bring these items.
2. Publicity Release: I authorize pictures and/or videos of my child to be used for publicity and marketing purposes on the Ramat Shalom website, newspapers, magazines, social media, or marketing materials. ______Yes ______No (Please initial) ______
Enclosed is check #______in the amount of $______
OR Charge my credit card on file _____ OR (fill in Credit Card information below)
American Express, Visa or MasterCard #______
Print Name on Credit Card: ______Expiration Date ______
Billing Address for Credit Card: ______
Contact Numbers: Home ______Cell ______
E-mail Address(s): ______
Parent’s Printed Name: ______Signature: ______Date: ______
PLEASE COMPLETE THE YOUTH INFORMATION FORM ON PAGE 2
Youth Information
Name (Last, First) ______
DOB______Age______Grade_____ as of 8/2012
Youth’s Contact Information:
Phone Numbers: Home ______Cell ______
E-mail Address______
Home Address______
Parent/Guardian and Emergency Contact Information:
1) Name (Last, First) ______
Phone Numbers: Home ______Cell ______
Work______E-mail Address______
Home Address______
2) Name (Last, First) ______
Phone Numbers: Home ______Cell______
Work______E-mail______
Home Address______
Medical Information:
My child, ______, has the following medical conditions, allergies and takes the following
(print child’s name)
prescription medications Ramat Shalom needs to be aware of :
Example: asthma, reaction to insect bites, benedryl needed , etc.
______
______
______
Insurance Company______Policy Number______
Policyholder is Employed By: ______
Parent/Guardian Signature: ______Printed Name: ______