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Daily Service / Class Schedule
Bar Mitzvah Preparation
Checking Mezuzot and Tefillin
Home / Office Classes with the Rabbi
Kids Torah Zone Registration Form
Mitzva Project
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Calendar
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
Daily Service / Class Schedule
Bar Mitzvah Preparation
Checking Mezuzot and Tefillin
Home / Office Classes with the Rabbi
Kids Torah Zone Registration Form
Mitzva Project
Gallery
Calendar
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
