For returning families click here. Summer Registration CHILD'S INFOChild's Name* First and Middle Last Name to be called* Child's Hebrew Name* Date of Birth* MM slash DD slash YYYY Gender* Male Female Previous School or Day Care* Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code PARENT'S INFOMother's InfoTitle*Mrs.Dr.Full Name* First Last Hebrew Name* Date of Birth* MM slash DD slash YYYY Cell Number*Work Number*Occupation and Place of Employment* Email* Is the child's birth mother Jewish from birth?*YesNoFather's InfoTitle*Mr.Dr.Full Name* First Last Hebrew Name* Date of Birth* MM slash DD slash YYYY Cell Phone*Work Phone*Occupation and Place of Employment* Email* Family InfoAre the child's parents married* Yes No Any Custody - Visiting Arrangements? Are there any adoptions or conversions on mother's side of the family* Yes No If yes, please explain If child is adopted, list age of adoption Is child aware of adoption? Are you affiliated with any synagogue or religious organization?YesNoNo, but we would be interested in joining oneIf yes, please specify Child's Medical InformationDoes your child have any medical conditions?* Yes No Please Specify Does your child have any allergies?* Yes No Please Specify Has your child ever been evaluated for developmental delays or has an evaluation been recommended in the past?* Yes No Please Elaborate Is your child taking any medications?* Yes No Please Specify Pediatrician Name* Pediatrician's Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest 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* Child's Profile - Background InformationLanguages Spoken at Home List Child's Siblings and Their Ages Does your child have special food or eating instructions? Is your child toilet trained? If in progress, please explain* Describe assistance needed and words used Does your child have any fears?* What are your child's favorite activities? Is there any additional information, such as child's communication, discipline, or family circumstances that you feel we should know about? Please check the adjectives below that describe your child:* Happy Aggressive Friendly Moody Independent Dependent Stubborn Fearful Good-natured Quiet Impulsive Even-tempered Attentive Determined Shy How did you hear about Gani Preschool?* 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 Child EMERGENCY 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 & RELEASEHEALTH RISK ACKNOWLEDGEMENT WAIVER & RELEASE On 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 wear personal protective equipment such as face masks and gloves, and follow any and all other 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* MM slash DD slash YYYY ScheduleSelect your choice of four day or two day option.* Four days per week (MTTF) $575 Two days per week - Monday & Thursday - $300 Two days per week - Tuesday & Friday - $300 Full Day: 9:30 AM - 1:00 PMLet us know if you would like two different days. We will do our best to accommodate: Please review your application before submitting* I have reviewed the application, and hereby register my child for Summer 2020.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 summer program. 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 MM slash DD slash YYYY Non-Refundable Registration Fee* Price: Total $0.00 Credit Card American ExpressDiscoverMasterCardVisaSupported Credit Cards: American Express, Discover, MasterCard, Visa Card Number Month010203040506070809101112 Year20242025202620272028202920302031203220332034203520362037203820392040204120422043 Expiration Date Security Code Cardholder Name 2020-06-10
