ECC Registration

2020-2021 Family Information and Photo Waiver - Confidential

* Indicates required field

Child's Name *

First

Last

Birth Date *

Gender *

Male Female

Entering Class (e.g. 2's, 3's, or 4's) *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Family’s religious affiliation *

Other Children in the family and their ages *

Child’s Special Needs (allergies, etc.) *

Home Phone Number *

Which Kindergarten will your child attend? *

First Parents Name *

First

Last

Cell Phone Number *

Email *

First Parents Profession *

Second Parent's Name *

First

Last

Phone Number *

Email *

Second Parent’s Profession *

Photo Images
From time to time, The Community Synagogue of Rye and the Early Childhood Center like to publish images of the ECC classes and activities. No child is ever identified without specific permission from a parent. If you would prefer your child
NOT be pictured.

Permissions *

I do not give permission for the Early Childhood Center to use likenesses of my child for internal purposes such as: the Synagogue Bulletin, ECC publications, other print materials and internal emails with the understanding that no child’s name will be published. I do not give permission for the Early Childhood Center to use likenesses of my child in public media such as: local newspapers, the Synagogue’s website and social media with the understanding that no child’s name will be published. I give permission for the Early Childhood Center to use likenesses of my child for internal and external purposes.

For any question related to membership or the congregation, please contact our Executive Director, Glynis Conyer at gconyer@comsynrye.org or 914-967-6262.

Submit

ALLERGY ALERT FORM

The purpose of this form is to alert the school of any known allergies.

IMPORTANT NOTE:
ANY CHILD REQUIRING SPECIAL HEALTHCARE NEEDS OR MEDICATION MUST PROVIDE INFORMATION ON AN ADDITIONAL FORM.
NO MEDICATION WILL BE ADMINISTERED WITHOUT AN APPROVED MEDICAL CONSENT FORM.

Click to download: Child Medical Statement Medical Consent Form Non Medical Consent Form

* Indicates required field

Child’s Name *

First

Last

Date of Birth *

Choose Any *

My Child has NO KNOWN ALLERGIES

Date *

MY Child HAS THE FOLLOWING ALLERGIES: *

Emergency Action Required: *

Emergency Contact #1 *

First

Last

Emergency Contact Phone #1 *

Other Phone #1 *

Emergency Contact #2 *

First

Last

Emergency Contact Phone #2 *

Other Phone #2 *

Does your child require medication? *

Choose Any *

I have provided a written Medical Consent Form

Choose Any *

I have provided an Individual Health Care Plan

Submit

ECC Emergency Information Card

* Indicates required field

Child’s Name *

First

Last

Date of Birth *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Parent's Name 1 *

First

Last

Parent 1 Cell Phone *

Parent 1 Home Phone *

Parent's Name 2 *

First

Last

Allergy Alert *

Parent 2 Cell Phone *

Parent 2 Home Phone *

If a parent cannot be reached, list 3 local contacts who you would like to be notified. Please indicate each person's relationship to the child.

Local Contact 1 *

First

Last

Local Contact 2 *

First

Last

Local Contact 3 *

First

Last

Local Contact 1 Cell Phone *

Local Contact 2 Cell Phone *

Local Contact 3 Cell Phone *

Local Contact 1 Home Phone *

Local Contact 2 Home Phone *

Phone Number *

Physician's Name *

First

Last

Physician's Phone *

Please complete and submit this form before the first day of school.

EMERGENCY CARD - Permission Statement

I give permission to Community Synagogue Early Childhood Center to take emergency measures as judged necessary for the care and protection of my child while under their supervision.

In case of medical emergency, I understand that I deemed necessary by the local emergency medical providers (i.e. EMS) my child will be transported to an appropriate medical facility by the local emergency unit.

It is understood that in some medical situations, the staff will need to contact the local emergency resource before the parent, child's physician and/or other adult acting on the parent's behalf.

Parent/Guardian's Name *

First

Last

Today's Date *

Submit

Child's History

* Indicates required field

Child's Name *

First

Last

Parent's Name 1 *

First

Last

Parent's Name 2 *

First

Last

EARLY DEVELOPMENTAL HISTORY

Choose Any *

Premature

A. Any serious health problems during 1st year of life? (illness, surgery, accidents, hospitalized): *

B. Is your child toilet trained? *

CURRENT PERSONALITY & SOCIAL ADJUSTMENT

A. Does he/she have any fears that we should be aware of at this time? *

C. What do you find most challenging about your child? *

E. Does your child have any special needs; and if so has he/she ever received or is presently receiving any services? *

B. What do you as parents find most enjoyable about your child? *

D. What aspects of his/her development do you feel we need to work on together? *

F. Please add any other information you would like us to know about your child? *

Submit

2020-2021 Family Information and Photo Waiver - Confidential

ALLERGY ALERT FORM

ECC Emergency Information Card

EMERGENCY CARD - Permission Statement

Child's History

EARLY DEVELOPMENTAL HISTORY

CURRENT PERSONALITY & SOCIAL ADJUSTMENT

Community Synagogue of Rye
200 Forest Avenue
Rye, NY 10580

Office: 914-967-6262
Fax: 914-940-6552
info@comsynrye.org

ECC: 914-967-7698
CJL: 914-967-7598

2020-2021 Family Information and Photo Waiver - Confidential

​ALLERGY ALERT FORM

ECC Emergency Information Card

EMERGENCY CARD - Permission Statement

Child's History

EARLY DEVELOPMENTAL HISTORY

CURRENT PERSONALITY & SOCIAL ADJUSTMENT

Community Synagogue of Rye200 Forest AvenueRye, NY 10580

Office: 914-967-6262Fax: 914-940-6552info@comsynrye.org

ECC: 914-967-7698CJL: 914-967-7598

ALLERGY ALERT FORM

Community Synagogue of Rye
200 Forest Avenue
Rye, NY 10580

Office: 914-967-6262
Fax: 914-940-6552
info@comsynrye.org

ECC: 914-967-7698
CJL: 914-967-7598