Registration Form For STRATEGIC HEBREW City Explorers Program SUMMER 2015

Strategic Hebrew, Inc.
www.StrategicHebrew.com
Amy@StrategicHebrew.com
732-70 SPEAK (77325)
REGISTRATIONFORMfor
STRATEGICHEBREWCityExplorersProgramSUMMER2015
Explorerinformation:
Name__________________________________Birthdate___________________________
MailingAddress____________________________________________________________________
Email___________________________________
CellPhone__________________________
GradeasofFall2015_______________________
School_______________________________
Parent1information(primarycontact):
Name___________________________________
HomePhone________________________
EmailAddress____________________________
CellPhone__________________________
Bestwaytoreachyou(pleasecircle)
WorkPhone________________________
Email
Phone
Home/Cell/Work
Parent2information(secondarycontact):
Name_________________________ HomePhone________________________
EmailAddress___________________ CellPhone__________________________
Bestwaytoreachyou(pleasecircle)
WorkPhone_____________________
Email
Phone
Home/Cell/Work
EXPLORERSPLEDGE:
IamlookingforwardtotakingpartintheStrategicHebrewCityExplorersprogram.
IagreetoparticipatewithanopenmindanddomybesttospeakinHebrewthroughouttheweek.
ExplorerSignature_______________________________________
Date____________________
GuardianSignature_______________________________________
Relationship______________
Pleasemailyournonrefundabledepositof$150to665WestEndAvenue,Suite1B,NYNY10025.Full
paymentmustbereceivedbyMay1
(circleone)
.MakechecksouttoStrategicHebrew,Inc.
Regular
EarlyBird(ends3/2)
DiscountCode(ifapplicable)
5DayProgram
$395
$325
___________________
EarlyDropOff
$15/dayor$60/week

732-70 SPEAK (77325)
INCASEOFEMERGENCY
Wewillnotifytheprimarycontactparentbyphonefirst.Intheeventthatneitherparentcanbe
reached,pleaseprovideuswithalocalemergencycontactwhowillbeavailableduringthe
programhoursandhasknowledgeofanymedicalconditionsspecifictoyourchild.
EmergencyContact:
Name_________________________
HomePhone________________________
RelationshiptoExplorer:
CellPhone__________________________
______________________________
WorkPhone_____________________
HealthCareProvider
Name_________________________
Phone________________________
InsuranceCarrier:_________________________
Policy#__________________________________
Doesyourchildhaveanyallergies?Pleasedescribetriggers(i.e.airborne,contact,etc.)
andtreatment(doeschildcarryepipen,etc.):
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
Isthereanythingelseweshouldknowaboutyourchildinordertoprotecthis/hersafety
duringthisprogram?
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

732-70 SPEAK (77325)
PARENTQUESTIONNAIRE
DearParents,
Inoureffortstoprovideacomfortableandenrichingenvironmentforyourchildtodevelophis/herHebrew
skills,yourfeedbackisveryimportanttous.Pleasetakeamomenttoanswerafewbaselinequestionsthat
willhelpusevaluatethesuccessoftheprogram.
Ifyouhaveanyquestionsorconcernsleadinguptotheprogramorduringtheprogramitself,pleasedont
hesitatetoreachoutbyphone(7327077325)oremail(
amy@StrategicHebrew.com
).Welookforwardtoa
fun,mindbroadeningexperiencewithyourchildthissummer!
HowimportantisHebrewlanguageinyourhousehold?
Least
1
2
3
4
5
6
7
8
9
10
Most
HowfrequentlyisHebrewspokenwithinyourhousehold?
Least
1
2
3
4
5
6
7
8
9
10
Most
InwhatcontextisHebrewspokenmost?
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
Whatdoyouhopeyourchildwillgainfromthisfellowship?
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
Doyouhaveanyquestionsabouttheprogramasdescribedand/oryourchilds
participationinthefellowship?
_____________________________________________________________________
_____________________________________________________________________
____________________________________________________________________
_

732-70 SPEAK (77325)
PhotoandTechnologyRelease:
AsStrategicHebrewSpeakerslearnandgrowintheirfacilitywiththeHebrewlanguage,wecreatejournal
entries,photosandvideoclipstodocumenttheirprocess.Thistangibleevidencewillallowsstudentstosee
exactlyhowfartheyhavecomeandwillbecomeasourceofprideandconfidenceaslessonscontinueover
time.
Pleasesignandreturnthisformtoacknowledgethattheseportfoliomaterialswillalsobearchivedby
StrategicHebrew,Inc.andmaybeusedbyStrategicHebrew,Inc.fordocumentaryandpublicitypurposes,
includingpostingonthewebsite,newsletters,facebookandotherforums.Thisdocumentarymaterialwillnot
bedistributedtoanythirdpartyandwillonlybeusedbyStrategicHebrew,Inc.fortraininganddevelopment.
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Acknowledgement:
Ihavereadandunderstandtheaboveletterandconsentformychildandmychilds
worktobepicturedindocumentaryandpublicitymaterialsfortheexpressuseofStrategicHebrew,Inc.
FellowsName:___________________________________
GuardianSignature_______________________________Date_______________________
**************************************************************
FieldTripPermissionForm:
TheStrategicHebrewExplorersprogramwilltakeplaceinmuseums,zoos,parksandattractionsthroughout
NewYorkCity.DetaileditinerarywillbesenttoregisteredparticipantsinearlyJune.Meetingplaceswillbein
Manhattan,determinedbyvenuelocation.Ifthereisenoughinterest,additionalmeetingpointscanbe
arrangedinstudentneighborhoods.
Pleasesignbelowtoadviseusofyourpreferredarrival/dismissalplans.
**
Consent:
IgivemychildpermissiontotakepartinthefieldtripsassociatedwiththeStrategicHebrewCity
ExplorersProgramandtotravelbetweenvenuesduringthecourseofthedayasperprogramschedule.
_____ Mychildwillbepickedupattheendoftheday(nolaterthan3PM).
_____Mychildhaspermissiontoleaveonhis/herownattheendoftheday.
ExplorerName(print):____________________________________________________________________
GuardianSignature_______________________________
Date______________________________
Nameofcaregiver(s)whowillpickupexplorerattheendoftheday:
Name____________________________________
Phone___________________________________
Name____________________________________
Phone___________________________________

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