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Bar Mitzvah Preparation
Checking Mezuzot and Tefillin
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Kids Torah Zone Registration Form
Mitzva Project
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Blog
Contact Us
Tiferet Rafael
9665 W. Broward Blvd
Plantation, FL 33324
Home
About
About the Community
About the Rabbi
Ask the Rabbi
Join
Donations
Services
Bar Mitzvah Preparation
Checking Mezuzot and Tefillin
Home / Office Classes with the Rabbi
Kids Torah Zone Registration Form
Mitzva Project
Wedding Ceremony
Gallery
Calendar
Blog
Contact Us
Chalutzim – About
Chalutzim – Learn More
Chalutzim – Register
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
