ELC Family Information Form

Early Learning Center Family Information Form

Parent/Guardian Information

Parent/Guardian 1

Parent/Guardian 2

Title

Last Name

First Name

Date of Birth (m/d/y)

Click on month, date, year to type in change; or click on arrow at right of box to select from calendar.

Date of Birth (m/d/y)

Click on month, date, year to type in change; or click on arrow at right of box to select from calendar.

Marital Status

Email Address

Occupation/Title

Mobile Phone

Date of Marriage (if applicable)

Address Information

Residence Street

Apartment #

City

State

Zip Code

Home Phone Number

Billing Address (if different)

Billing Street Address

Apartment #

City

State

Zip Code

Family Information

Children (please complete as it applies to each of your children residing with you)

1st Child

2nd Child

3rd Child

4th Child

Last Name

First Name

Birth Date

Click on month, date, year to type in change; or click on arrow at right of box to select from calendar.

Birth Date

Gender

School Grade Fall 2021

if enrolled in a K-12 school

School Grade Fall 2021

if enrolled in a K-12 school

School Grade Fall 2021

if enrolled in a K-12 school

School Grade Fall 2021

if enrolled in a K-12 school

Secular School/College Name

Adult Children (25 years or older) Not Residing With You

1st Child

2nd Child

3rd Child

4th Child

Last Name

First Name

Hebrew Name

Birth Date

Age

Gender

College Student?

College Name

Other Adults in Your Household

1st Adult

2nd Adult

3rd Adult

Name

Age

Relationship

Yahrzeit Information (Optional)
If provided we will notify you up upcoming dates and include in services on appropriate dates.

Please list the names of loved ones for whom you wish Yahrzeit notices sent

Name of Deceased

Relationship

Member 1 or 2?

Secular Date

Click on month, date, year to type in change; or click on arrow at right of box to select from calendar.

Name of Deceased

Relationship

Member 1 or 2?

Secular Date

Name of Deceased

Relationship

Member 1 or 2?

Secular Date

Name of Deceased

Relationship

Member 1 or 2?

Secular Date

Name of Deceased

Relationship

Member 1 or 2?

Secular Date

Religious Background (Optional)

Member 1

Member 2

Religious tradition in which you were raised

If not raised in the Jewish tradition, are you

Hebrew Name (if applicable)

Bar / Bat Mitzvah?

Confirmation?

Hebrew Fluency

Miscellaneous Information

How did you hear about Temple Shaari Emeth?

Name of previous Congregation affiliation:

City / State

Year left:

Agreement

The undersigned hereby confirm that they have completed this room truthfully. Enrollment in the Early Learning Center is completed separately after sign-in credentials are sent to you.

Member 1

Writing your name here is the equivalent of your signature. You are agreeing to the above as conditions of membership.

Member 2

Writing your name here is the equivalent of your signature. You are agreeing to the above as conditions of membership.

Thu, June 1 2023 12 Sivan 5783