Atlanta Keshet registration form 2019-2020





IAC Keshet Atlanta Registration Form


Thank you for your interest in joining the IAC Keshet program.

This registration form provides us with information essential to best serve you and your child(ren).

Should any of the information change, please contact us IMMEDIATELY with the updated information.


First Child's Information








Allergies










Health Insurance


*You will be asked to provide a copy of your insurance card.

Whenever feasible, please contact the following Doctor when an emergency occurs.


Second Child's Information








Allergies










Health Insurance


*You will be asked to provide a copy of your insurance card.

Whenever feasible, please contact the following Doctor when an emergency occurs.


Third Child's Information








Allergies










Health Insurance


*You will be asked to provide a copy of your insurance card.

Whenever feasible, please contact the following Doctor when an emergency occurs.


Contact Information














Please List Two Emergency Contacts (In addition to the Parent/Guardian)






Medical Information & Release
In case of injury or illness of a child while at IAC Keshet, every effort will be made to contact a parent or guardian. If you cannot be reached, we will call the emergency contacts you listed, or your child's doctor - or an ambulance, if necessary.


Pick-Up Authorization
The following people have my permission to pick up my child from IAC Keshet






Note: For any reason if a different person needs to pick up your child, you must inform your child’s counselor ahead of time.

Authorizations and Disclaimer


IAC Reserve the right to remove any child from the Keshet Program. 
Payment Information