ECLC Student Information Form 2022-23

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Please read through everything. If you have any questions, contact our office.

Child's Information

* Child's Name

* What class is your child in:

Parent(s) Information

* Parent Name

* Email

* Primary Phone #:

Parent 2 Name

Primary Phone #:

Pickup / Release Authorization List

Please list the names and phone numbers of anyone who has permission to pick up your child other than parents. We cannot release your child to anyone except those listed below. Please notify our office of any changes.

* Name

* Relationship:

* Phone Number:

Name

Relationship:

Phone Number:

Name

Relationship:

Phone Number:

Name

Relationship:

Phone Number:

Emergency Contact Information

* Emergency Contact (if parent or guardian is unavailable)

* Relationship

* Best method of contact

In the event of an emergency involving my child and I cannot be reached, I give consent for Temple Israel Early Childhood Learning Center to seek appropriate medical care, with the understanding that I will be notifies as soon as possible of any such incident. In the event of a medical or surgical emergency, if I or my emergency contacts cannot be reached, I grant permission to the physician designated by Temple Israel ECLC to hospitalize secure proper and necessary treatment for and order injections, anesthesia or surgery for my child, solely to the extent necessary until I can be reached.

* Yes, I give consent

Yes, I give consent

Medical Information

* Please list any allergies/special health considerations we should know about. Please indicate if there are no known allergies

* Pediatrician

* Phone Number

* Address

* Insurance Company

* Member ID

* Policy Holder

* Please upload your insurance card

Permission Slip

I give permission for my child to take local trips with his/her class. I understand that the children will be adequately supervised and accompanied by their teachers at all times. We will provide advanced notice if they travel more than 3 blocks.

* Yes, I agree

Yes, I agree

Sat, April 20 2024
12 Nisan 5784

After-School Enrichment

Our after-school enrichment programs are a great way to supplement your child’s school day in a safe and age-appropriate environment. There are a wide variety of choices each semester to cater to your child’s individual interests.

Challah Registration

There is no more perfect way to celebrate the end of the school week and the beginning of Shabbat than with a yummy, freshly baked challah. Whether your child is bringing home chocolate chip or whole wheat, you will always be prepared for Friday Night with leftovers for French toast on Saturday morning!

Pizza Registration

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Sat, April 20 2024 12 Nisan 5784