2024 Children/Teen Purim Program

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* Child/teen #1 name

Child/teen age

Child/teen #2 name

Child/teen age

Child/teen #3 name

Child/teen age

* First and last name of parent to be contacted if necessary

Parents of children in 3rd and 4th grade need to be in the building while their children are in the downstairs program.

* Phone number

* Email

* Check all that apply:

I will pick my child(ren) up from the program by 11:30pm.My child(ren)/teen has permission to walk home at the end of the program unaccompanied (teens 15 and older may accompany younger sibling(s).

Due to the lateness of this event, children under the age of 15 may not leave the building alone. They must be picked up by the parent or guardian listed on this form or with an older sibling listed on this form. They may not leave with a teen that is not related to them.
Teens aged 15 and over are permitted to leave the building alone provided their parent or guardian has given us express permission by checking the appropriate box on this form.
Teens aged 15 and over are permitted to leave the building with their younger siblings (and unaccompanied by a parent or guardian) provided their parent or guardian has given us express permission by checking the appropriate box on this form. They may not take home a child that is not related to them.

* List the names of parent(s)/guardian(s) that can get your child(ren)/teens.

* EMERGENCY MEDICAL CARE AUTHORIZATION: BZBI shall make every effort to first notify the parents or guardians in the event of a medical emergency. If this is not possible and the staff who are present deem it necessary, I authorize BZBI staff to obtain care and treatment for the child, including: permission for BZBI staff to perform first aid and/or arrange for emergency response and hospitalization.

EMERGENCY MEDICAL CARE AUTHORIZATION: BZBI shall make every effort to first notify the parents or guardians in the event of a medical emergency. If this is not possible and the staff who are present deem it necessary, I authorize BZBI staff to obtain care and treatment for the child, including: permission for BZBI staff to perform first aid and/or arrange for emergency response and hospitalization.

* Please type your name here to indicate agreement

* $5 per child/teen ($10 at the door)

$5 for 1 child/teen$10 for 2 children/teens$15 for 3 children/teens

Total Due

Sun, May 12 2024 4 Iyyar 5784