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SUPPORT US
Machane Emanuel - December 2022
Please verify reCaptcha before submitting the form.
The form is now closed.
If you'd like to inquire about your child attending, please contact Donny at
donny@emanuel.org.au
"
Contact Information
First Name
Last Name
Relationship to child(ren) being enrolled
Please Select One
Parent
Grandparent
Aunt/Uncle
Family Friend
Other
Mobile Phone
Email
Student Enrolment
Cost for the program is
$75 per day.
A 10% discount is applied against fees for the first sibling ($67.50 per day).
A 15% discount is applied against fees for the second sibling ($63.75 per day).
First Name
Last Name
Date of Birth
Please select which days you'd like to book:
Monday 19 December 2022
Tuesday 20 December 2022
Wednesday 21 December 2022
Thursday 22 December 2022
Is your child on any regular medication? (Y/N) If yes, which?
Does your child suffer from any allergies? (Y/N) If yes, which?
First Name
Last Name
Date of Birth
Please select which days you'd like to book:
Monday 19 December 2022
Tuesday 20 December 2022
Wednesday 21 December 2022
Thursday 22 December 2022
Is your child on any regular medication? (Y/N) If yes, which?
Does your child suffer from any allergies? (Y/N) If yes, which?
First Name
Last Name
Date of Birth
Please select which days you'd like to book:
Monday 19 December 2022
Tuesday 20 December 2022
Wednesday 21 December 2022
Thursday 22 December 2022
Is your child on any regular medication? (Y/N) If yes, which?
Does your child suffer from any allergies? (Y/N) If yes, which?
Emergency Contact Information
Last Name
First Name
Relationship to child(ren) being enrolled
Please Select One
Parent
Grandparent
Aunt/Uncle
Family Friend
Other
Mobile
Email
Emergency Medical Care Information
Family Medicare Number
Medicare Reference Number (Child 1)
Medicare Reference Number (Child 2) (if applic)
Medicare Reference Number (Child 3) (if applic)
Private Health Fund (Name)
Private Health Fund Membership Number
Name of Family Physician
Phone Number for Family Physician
Address of Family Physician
Consent for Medical Care
In the event of an emergency involving my child(ren) I give my consent for Emanuel Synagogue Hebrew and Religion School to seek and administer the appropriate medical care at my expense, with the understanding that I will be notified as soon as possible of any such incident.
Consent for Medical Care
Please Select One
Yes
No
Consent for Photography
I give permission for my child(ren)’s photos or student work, including my child(ren)’s names, to be used in communications about the Emanuel Synagogue Hebrew & Religion School. This may include publicity in Emanuel Synagogue newsletters, the Australian Jewish News, the Emanuel Synagogue website and other similar publications.
Photography Consent
Please Select One
Yes
No
Release & Indemnity
I agree that neither Emanuel Synagogue, Emanuel Synagogue Hebrew and Religion School, nor the Board of Progressive Jewish Education (BPJE) will be responsible for any injury or loss which my child(ren) may suffer while attending the school. I accordingly hereby release Emanuel Synagogue, Emanuel Synagogue Hebrew and Religion School and BPJE, as well as any of its officers, staff (both administrative and non-administrative) from any liability for any such injury or loss and indemnify each of them against all actions, claims or proceedings which may be brought against all or any of them by reason thereof.
Release & Indemnity
Please Select One
Yes
No
Payment Section
Cost for the program is
$75 per day.
A 10% discount is applied against fees for the first sibling.
A 15% discount is applied against fees for the second sibling.
Please upload your Creative Kids voucher(s)
You can upload a maximum of 4 files.
Credit Card Number
Expiry Date
CCV
Creative Kids vouchers may take
up to a week
to process.
A receipt will be issued to you from the Finance Team upon processing of camp fees.
Mon, 30 January 2023
8 Shevat 5783
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Mon, 30 January 2023 8 Shevat 5783