Kaytana and Kadima Summer 2019

Child's Name:*
Date of Birth*
Age at beginning of scheme
Family E-mail Address:*
Home Phone:
Child's School
School Year:
EHRS Member?
Synagogue Membership
Parent 1 name
Parent 1 Mobile
Parent 1 work number:
Parent's 1 address different?
Parent 1 Address:
Parent 2 name
Parent 2 Mobile
parent 2 work number
Parent's 2 address different?
Parent 2 Address:

Additional names and contact numbers
(excluding parents above)

Any additional Contacts
Addtional 1
Addtional 2
Addtional 3

Please list below the adults who have your permission to collect your child from EHRS.

If a person who is not listed attempts to collect your child, we will not permit them to leave the premises.

If your child is to return home alone, a written and signed letter from the parent/guardian must be given to the Senior Youth Worker or Youth Centre Manager in advance.

Permitted to Collect:
Medical information
Any Allergies
Take any medication
Doctor name address and telephone

Week Attendance Charges

EARLY BIRD PRICES (before Friday 7 June)

Kaytana 5-7 & 8-10's Members
Kaytana 5-7 & 8-10's Non-Members
Kadima 11-14's Members
Kadima 11-14's Non-Members

REGULAR PRICES (on or after Friday 7 June)

Kaytana 5-7 & 8-10's Member
Kaytana 5-7 & 8-10's Non-Member
Kadima 11-14's Member
Kadima 11-14's Non-Member

Individual Days Attendance Charges

Kaytana & Kadima (non-trip days)
Kaytana & Kadima (trip days)
Please list individual days

Early Drop Off and Late Pickup Charges

Early drop off /Late pickup
Early/Late Dates
Please keep me updated with future information about activities and events at the EHRS Youth Centre*

agree to my child attending EHRS Kaytana/Kadima Play Scheme 2018 and taking part in all activities organised on the premises and at the local park. I am aware that photos of my child may be taken and used for EHRS publicity, Social Media and website. I agree to my child being given first aid treatment by qualified staff on or off the premises, and where necessary to be taken to hospital in an emergency. If I am not  contactable I agree to my child being given hospital treatment without me being present.

I will sign my child out each day.

Parent's Approval (name and dated to sign)