New York Keshet LSS Registration Form 2019-2020

Registration Fees (One Child) - LSS Member

Fall Semester (12 sessions) - $180Spring Semester (14 sessions) - $210Year (26 sessions) - $350

Registration Fees (One Child) - Non-Member

Fall Semester (12 sessions) - $360Spring Semester (14 sessions) - $420Year(26 sessions) - $702

Registration Fees (Two Children) - LSS Member

Fall Semester (12 sessions) - $360Spring Semester (14 sessions) - $420Year (26 sessions) - $700

Registration Fees (Two Children) - Non-Member

Fall Semester (12 sessions) - $720Spring Semester (14 sessions) - $840Year (26 sessions) - $1404

Registration Fees (Three Children) - LSS Member

Fall Semester (12 sessions) - $540Spring Semester (14 sessions) - $630Year (26 sessions) - $1050

Registration Fees (Three Children) - Non-Member

Fall Semester (12 sessions) - $1080Spring Semester (14 sessions) - $1260Year (26 sessions) - $2106

Total Amount before discount:

Promo Code:

Total Amount $:

Total Amount to be charged $:

Photo and Video Release Form for Children:I hereby release Keshet and IAC New York and IAC , its contractors, clients, employees, officers, legal heirs, investors, agents, representatives, and assigns from all liability for any claims by me, my minor child, my family, my heirs, legal representatives and assigns or any third party in connection with my child’s participation, including any claims and demands ensuing from or in connection with the use of the photos and videos, including any and all claims for libel and invasion of privacy. I also release them from any expectation of confidentiality for the use of said photographs.*

I hereby give authority to IAC Keshet staff to obtain necessary emergency medical treatment for my child with the understanding that the family will be notified as soon as possible.*

I certify that my child has no known medical or other conditions that could interfere with his/her participation in IAC Keshet activities.*

I understand that in case of an emergency, me or the emergency contacts I provided will be contacted. If necessary, my child will be taken to the emergency room of the nearest hospital. I understand that I will be responsible for any and all payments subsequent as well as any and all follow ups that medical staff deem necessary.*

The IAC Keshet staff may take my child for short neighborhood walks/park.*

While supervised, my child is allowed to play in a playground.*

My Capacity and Authorization:I warrant and represent that I am the parent or guardian of the participating minor. I understand English. I have read this authorization, release, and agreement in full, prior to its execution, and I fully understand the contents thereof.*

Israeli American Council (IAC) Keshet does not discriminate any person on the basis of race, color, religion, sex, gender, identity or expression, sexual orientation, national origin, age, disability, marital status, family status or any other characteristic protected by Federal and State laws. IAC Keshet can only offer reasonable accommodation for one with some form of disability. IAC Keshet reserves the right to interview all applicant families.Israeli American Council (IAC) Keshet will make reasonable accommodations in compliance with the Americans with Disabilities Act of 1990.*

Please check the I ACCEPT box indicating your authorization. Checking the I ACCEPT box is legally equivalent to your actually signing this document.

I ACCEPT

Please check the I ACCEPT box indicating that you understand it is your responsibility to immediately update all information on this form. To not do so may diminish IAC Keshet’s ability to probably address the needs of your child(ren) and/or to make needed contact should an emergency occur.

I ACCEPT