Hebrew Reading Room - JewishNortheast.com

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Parents Information
Father's Name*
First NameLast Name
Father Cell
Area CodePhone Number
Mother's Name*
First NameLast Name
Mother Cell
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Emergency Medical Information
Emergency contact 1:*
First NameLast Name
Relationship to child:*
Phone Number*
Area CodePhone Number
Emergency contact 2:
First NameLast Name
Relationship to child:
Phone Number
Area CodePhone Number
Physician's name:*
First NameLast Name
Physician's phone number:*
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CONFIDENTIAL: Does your child have any allergies or other medical condition we should be aware of? If yes, please describe them and indicate special precautions or care needed.*
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Hebrew Reading Room Registration