Membership Form

Registration Form
Adult 1 First Name
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Adult 1 Last Name
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Adult 2 First Name
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Adult 2 Last Name
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Street Address
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City
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Zip Code
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Home Phone Number
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Email Adult 1
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Cell Phone Adult 1
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Email Adult 2
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Cell Phone Adult 2
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Child 1 Name
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Child 1 Birthday (dd/mm/yyyy)
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Will Child 1 join us for Beit Midrash?
Child 1 Secular School Name
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Child 1 Grade
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Child 1 Grade
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Child 1 Allergies
Only Necessary if your child will be in Beit Midrash
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Child 1 additional information we should know. What successful strategies from home or school can you share to help your child’s teacher at the Beit Midrash?
Only Necessary if your child will be in Beit Midrash
Your answer
Child 2 Name
Your answer
Child 2 Birthday (dd/mm/yyyy)
Your answer
Will Child 2 join us for Beit Midrash?
Child 2 Secular School Name
Your answer
Child 2 Grade
Your answer
Child 2 Allergies
Only Necessary if your child will be in Beit Midrash
Your answer
Child 2 additional information we should know. What successful strategies from home or school can you share to help your child’s teacher at the Beit Midrash?
Only Necessary if your child will be in Beit Midrash
Your answer
Child 3 Name
Your answer
Child 3 Birthday (dd/mm/yyyy)
Your answer
Will Child 3 join us for Beit Midrash?
Child 3 Secular School Name
Your answer
Child 3 Grade
Your answer
Child 3 Allergies
Only Necessary if your child will be in Beit Midrash
Your answer
Child 3 additional information we should know. What successful strategies from home or school can you share to help your child’s teacher at the Beit Midrash?
Only Necessary if your child will be in Beit Midrash
Your answer
Please provide an Emergency Contact Name and Phone Number.
Only Necessary if your child will be in Beit Midrash
Your answer
I give permission to publish information in the Derech HaLev directory so members can continue to form relationships with me/ my family outside of Derech HaLev.
I grant permission that my family member's picture can we taken and published electronically without their name.
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