Returning Student Registration CHILD'S INFOChild's Name* First and Middle Last Child's Hebrew Name*Date of Birth* Date Format: MM slash DD slash YYYY Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country PARENT'S INFOMother's InfoTitle*Mrs.Dr.Full Name* First Last Hebrew Name*Date of Birth* Date Format: MM slash DD slash YYYY Cell Number*Work Number*Occupation and Place of Employment*Email* Father's InfoTitle*Mr.Dr.Full Name* First Last Hebrew Name*Date of Birth* Date Format: MM slash DD slash YYYY Cell Phone*Work Phone*Occupation and Place of Employment*Email* Child's Medical InformationDoes your child have any medical conditions?* Yes No Please SpecifyDoes your child have any allergies?* Yes No Please SpecifyHas your child ever been evaluated for developmental delays or has an evaluation been recommended in the past?* Yes No Please ElaborateIs your child taking any medications?* Yes No Please SpecifyPediatrician Name*Pediatrician's Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Pediatrician's Phone Number*Name of Insurance Policy*Policy Number*In case of a medical emergency requiring immediate emergency care, I hereby give permission to treat and transport my child by ambulance, to the nearest hospital necessary. I give permission for my child's medical information to be shared with medical staff.*Parent's SignatureCell Phone Number*PickupPersons authorized to pick up child*Additional InfoDoes your child have special food or eating instructions?Are there are any specific napping or sleeping instructions?*Is your child toilet trained? If in progress, please explain*Describe assistance needed and words usedDoes your child nap?* Yes No If yes, what time?My child wakes up in the morning at (specify time)and goes to sleep at (specify time)Does your child have any fears?*What methods of behavioral discipline are used in your home?Is there any additional information, such as child's communication, discipline, or family circumstances that you feel we should know about?Do you think your child will display separation anxiety on his/her first day at preschool?* Yes No Do any parent or close relatives have any special talent to share with our students?As you enroll your child in our program, please list the skills your child has mastered:EMERGENCY CONTACTSPlease indicate telephone numbers where you and another authorized person can be contacted in case of emergency:Parent 1 Name* First Last PhoneParent 2 Name First Last PhoneAdditional Authorized Person First Last PhoneRelationship to ChildEMERGENCY CONSENTIn case of emergency, I authorize the staff to provide any medical care or first aid deemed necessary for my child. In case of emergency, I hereby authorize transfer of care to my child's physician or local hospital and health records transfer. HEALTH RISK ACKNOWLEDGEMENT WAIVER & RELEASEOn March 4, 2020, California Governor Gavin Newsom declared a disaster emergency for California relating to the COVID‐19 outbreak. On March 11, 2020, the World Health Organization declared the COVID‐19 outbreak a global pandemic. On March 13, 2020, President Donald Trump declared the COVID‐19 outbreak a national health emergency. Given the severity of the COVID‐19 pandemic, and in anticipation of my child’s return to the care of Gani Jewish Preschool, a child care provider (“Facility”), I hereby make the following waiver, release and other representations and covenants set forth herein, on behalf of my child, and in favor of this Facility. Acceptance of Risk; Release; Indemnification. The safety and security of the children in its care remains a top priority of Facility. I understand that there is a risk associated with my child’s return to care at Facility, including but not limited to, increased social contact and interaction with Facility employees and other children. To help reduce the spread of COVID‐19 and to protect Facility employees and other children, Facility encourages all children and parents to adhere to all safety and health guidelines for the prevention of COVID‐19, including those issued by the California Department of Public Health and the Centers for Disease Control and Prevention. All persons should engage in frequent hand washing using soap and water for at least twenty seconds (or, if soap is not available, use an alcohol‐based hand sanitizer), sanitize surfaces and objects frequently used. Staff will follow preventive measures recommended by applicable authorities. Notwithstanding the foregoing, I understand that the above guidelines do not completely eliminate my child’s risk of exposure to COVID‐19 and, should my child experience any COVID‐19 related symptoms (such as fever, cough, body aches, or shortness of breath), I am advised to keep my child home, not to bring my child to the Facility, and follow the advice of my healthcare provider, clinic, or hospital. In such cases, I will immediately alert the Facility of such symptoms. Regardless of any steps taken by Facility to reduce the risks associated with the COVID‐19 pandemic, I am fully aware that there are a number of risks associated with my child’s care at Facility during the COVID‐19 pandemic, including without limitation, being exposed to and contracting COVID‐19 from other individuals, surfaces and/or airborne particles. I understand that my child’s contracting of COVID‐ 19 could result in serious medical symptoms requiring medical treatment in a hospital or even death. On behalf of myself and my child, and our heirs, successors, and assigns, I knowingly and freely, assume all such risks, both known and unknown, relating to my child’s care at Facility arising from or relating to COVID‐19, including all illnesses, injuries, damages or death arising therefrom, and I hereby forever release, waive, relinquish, and discharge Facility, along with Facility’s shareholders, officers, directors, members, managers, officials, partners, trustees, agents, contractors, employees, affiliates, or other representatives, and their successors and assigns (collectively, the “Facility Representatives”), from any and all claims, demands, liabilities, rights, damages, expenses, and causes of action of whatever kind or nature, and other losses of any kind, whether known or unknown, foreseen or unforeseen, (collectively, “Damages”) arising from or relating to COVID‐19 as a result of my child’s care at Facility, and including but not limited to claims based on the alleged negligence of any Facility Representative or any other person. I further promise not to sue Facility or any Facility Representative for any illness, injury, death or other Damages arising out of or related to COVID‐19 and agree to indemnify and hold them harmless from any and all Damages resulting therefrom as a result of my child’s care at Facility. If any provision of this Waiver and Release of Liability is declared invalid, the remaining provisions remain enforceable. I may seek advice from legal counsel before signing this Waiver and Release of Liability. By signing this Waiver and Release of Liability, I acknowledge that either I have sought the advice of legal counsel or wish to waive the opportunity to seek the advice of counsel before signing. READ CAREFULLY ‐‐ BY SIGNING THIS DOCUMENT YOU MAY GIVE UP IMPORTANT LEGAL RIGHTS. Parent's Signature*Date* Date Format: MM slash DD slash YYYY SchedulePlease note that there will be a fee for a schedule change. An additional $75 will be charged to anyone who changes their child's schedule before the first week of school, and a $150 fee will be charged for a schedule change after the first week of school.Full Day: 9:00 AM - 3:30 PM or Core Program : 9:00 AM - 12:30 PM*Select your choice of full day schedule 9:00 AM - 3:30 PM, or Core Program 9:00 AM - 12:30 PM5 full days per week (M-F) 9:00 AM - 3:30 PM5 half days per week (M-F) 9:00 AM - 12:30 PM3 full days per week (M,W,F) 9:00 AM - 3:30 PM3 half days per week (M,W,F) 9:00 AM - 12:30 PM2 full days per week (Tu,Th) 9:00 AM - 3:30 PM2 half days per week (Tu,Th) 9:00 AM - 12:30 PMPlease review your application before submitting* I have reviewed the application, and hereby register my child for the 2020-2021 school year. I have reviewed the application and guidelines. All the information I have provided on this form is true. I hereby register my child for the 2020-2021 school year. I also understand that once my child is accepted and contracts are signed, there are no refunds under any circumstances.Signature of Parent* Parent's Signature Date Date Format: MM slash DD slash YYYY Non-Refundable Registration Fee* Price: $75.00 Deposit*Non refundable deposit $175 (required to secure your child’s spot. Will be credited towards first month's tuition). Price: $175.00 Credit Card American ExpressDiscoverMasterCardVisa Card Number Month010203040506070809101112 Year20232024202520262027202820292030203120322033203420352036203720382039204020412042 Expiration Date Security Code Cardholder Name Coupon Total $0.00 2020-06-19