Keshet Payment 2022-2023Please enable JavaScript in your browser to complete this form.Parent InformationName *FirstLastEmail *Phone *Home Address *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeRegistrationHow many kids would you like to register? *123Participant InformationName *FirstLastHebrew NameBirth Date *Gender *FemaleMaleOtherIdentity *IsraeliIsraeli-AmericanJewish-AmericanOtherGrade Entering in 2022-2023 *Junior-KindergartenKindergarten1st Grade2nd Grade3rd Grade4th Grade5th GradeName of SchoolHebrew Level *UnderstandsSpeaksBothT-shirt size *XSSMLXLT2T3T4Does your kid have allergies? *YesNoList of allergies2nd Participant InformationName *FirstLastHebrew NameBirth Date *Gender *FemaleMaleOtherIdentity *IsraeliIsraeli-AmericanJewish-AmericanOtherGrade Entering in 2022-2023 *Junior-KindergartenKindergarten1st Grade2nd Grade3rd Grade4th Grade5th GradeName of SchoolHebrew Level *UnderstandsSpeaksBothT-shirt size *XSSMLXLT2T3T4Does your kid have allergies? *YesNoList of allergies3rd Participant InformationName *FirstLastHebrew NameBirth Date *Gender *FemaleMaleOtherIdentity *IsraeliIsraeli-AmericanJewish-AmericanOtherGrade Entering in 2022-2023 *Junior-KindergartenKindergarten1st Grade2nd Grade3rd Grade4th Grade5th GradeName of SchoolHebrew Level *UnderstandsSpeaksBothT-shirt size *XSSMLXLT2T3T4Does your kid have allergies? *YesNoList of allergiesHealth InformationHealth Insurance *Name of Health InsurancePolicy Number **You will be asked to provide a copy of your insurance card.Primary Care Doctor's Name *Doctor's phone number *Parent/Guardian #1 Name *FirstLastPhone Number *Email *Parent/Guardian #2 Name *FirstLastPhone Number *Email *Emergency contact #1 Name *FirstLastDifferent than parent/guardianPhone *Emergency contact #2 Name *FirstLastDifferent than parent/guardianPhone *Medical Information & Release In case of injury or illness of a child while at IAC Keshet, every effort will be made to contact a parent or guardian. If you cannot be reached, we will call the emergency contacts you listed, or your child's doctor - or an ambulance, if necessary.The following people have my permission to pick up my child from IAC KeshetPick-up Person #1 Name *FirstLastPhone * Relationship *Pick-up Person #2 Name *FirstLastPhone * Relationship *Note: For any reason if a different person needs to pick up your child, you must inform your child’s counselor ahead of time.Authorizations and DisclaimerPhoto and Video Release Form for Children: I hereby release Keshet and and IAC , its contractors, clients, employees, officers, legal heirs, investors, agents, representatives, and assigns from all liability for any claims by me, my minor child, my family, my heirs, legal representatives and assigns or any third party in connection with my child’s participation, including any claims and demands ensuing from or in connection with the use of the photos and videos, including any and all claims for libel and invasion of privacy. I also release them from any expectation of confidentiality for the use of said photographs.I hereby give authority to IAC Keshet staff to obtain necessary emergency medical treatment for my child with the understanding that the family will be notified as soon as possible.I certify that my child has no known medical or other conditions that could interfere with his/her participation in IAC Keshet activities.I understand that in case of an emergency, me or the emergency contacts I provided will be contacted. If necessary, my child will be taken to the emergency room of the nearest hospital.I understand that I will be responsible for any and all payments subsequent as well as any and all follow ups that medical staff deem necessary.The IAC Keshet staff may take my child for short neighborhood walks/park.While supervised, my child is allowed to play in a playground.My Capacity and Authorization: I warrant and represent that I am the parent or guardian of the participating minor. I understand English. I have read this authorization, release, and agreement in full, prior to its execution, and I fully understand the contents thereof.Israeli American Council (IAC) Keshet does not discriminate any person on the basis of race, color, religion, sex, gender, identity or expression, sexual orientation, national origin, age, disability, marital status, family status or any other characteristic protected by Federal and State laws. IAC Keshet can only offer reasonable accommodation for one with some form of disability. IAC Keshet reserves the right to interview all applicant families. Israeli American Council (IAC) Keshet will make reasonable accommodations in compliance with the Americans with Disabilities Act of 1990.Checking the I ACCEPT box is indicating your authorization and is legally equivalent to your actually signing this document. * I ACCEPTChecking the I ACCEPT box is indicating that you understand it is your responsibility to immediately update all information on this form. To not do so may diminish IAC Keshet’s ability to probably address the needs of your child(ren) and/or to make needed contact should an emergency occur. * I ACCEPTIAC Reserve the right to remove any child from the Keshet Program.Keshet thrives best with parental involvement and leadership. We are happy to invite you to take an active part in ensuring our mutual success. Please let us know the areas you would like to be involved in during our Keshet year. Choose one (or more) of the following:Parents committee Parental support during sessions Holidays and special events planning Administrative supportOtherPromo Code1 Keshet KidPrice: $ 360.002 Keshet KidsPrice: $ 684.003 Keshet KidsPrice: $ 1,008.00Total$ 0.00Stripe Credit Card *CardName on CardSubmit
