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Tiferet Rafael
9665 W. Broward Blvd
Plantation, FL 33324

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Chalutzim – About
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Chalutzim – Teachers

Kids Torah Zone Registration Form

The programs begins June 1st, 2022 and will meet weekly every Wednesday evening.

Cost is $25 per child, per month and includes materials and snacks.

To secure a space for your child(ren) fill out the form below.

Program fees for student registration:

One Child - $25

Two Children - $50

Three Children - $75

Parent/Guardian #1 Name(Required)

First Last

Parent/Guardian #1 Primary Phone(Required)

Parent/Guardian #1 Phone (Other)

Parent/Guardian #1 Email(Required)

Parent/Guardian #2 Name

First Last

Parent/Guardian #2 Primary Phone

Parent/Guardian #2 Phone (Other)

Parent/Guardian #2 Email

Home Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Emergency Contacts

Emergency contact #1 Name

Emergency contact #1 Phone

Emergency contact #1 Relationship to Child

Emergency contact #2 Name

Emergency contact #2 Phone

Emergency contact #2 Relationship to Child

The following are authorized to pick up my child from the program:

Authorized Pick up #1 Name

Authorized Pick up #1 Phone

Authorized Pick up #1 Relationship to Child

Authorized Pick up #2 Name

Authorized Pick up #2 Phone

Authorized Pick up #2 Relationship to Child

Authorized Pick up #3 Name

Authorized Pick up #3 Phone

Authorized Pick up #3 Relationship to Child

Authorizations and Disclaimer(Required)

I agree to the Authorizations and Disclaimer

I grant permission to Tiferet Rafael to use photographs and/or video images taken of me and members of my family for the purpose of publication, promotion, illustration, and advertising in any manner or in any medium. I release Tiferet Rafael and Israeli House in Miami from all claims and liability relating to said images / video. I waive my right to any compensation for use of such pictures and/or video images.

Enrolled Child/ren Information:

Child #1 Name

Child #1 DOB

Child #1 Phone

Child #1 Allergies?

Yes

No

Child #1 allergies

Child #2 Name

Child #2 DOB

Child #2 Phone

Child #2 Allergies?

Yes

No

Child #2 allergies

Child #3 Name

Child #3 DOB

Child #3 Phone

Child #3 Allergies?

Yes

No

Child #3 allergies

Credit Card

Card Details

Cardholder Name

By signing this form below you are indicating your authorization to Tiferet Rafael to charge your card monthly.

Signature(Required)

Total

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