Parental Release Form for Child Transfers to Levine JCC Programs - Levine Jewish Community Center, Charlotte, NC

Parental Release Form for Child Transfers to Levine JCC Programs/Courses

One form required per child per school year 2025-2026

RELEASE AUTHORIZATION

I give the Levine JCC permission to transfer my child to Levine JCC courses from the indicated school/program (CJP, CJDS, JTEAM). I will provide class specific transfer details per child/per class/per session at the time of registration. I understand that, upon transfer, the Levine JCC assumes responsibility for supervising my child. I agree to provide updated information via a new form submission if any information changes during the school year.

I give permission for my child to go swimming and to participate in active sports and all enrolled courses.

Parent/Guardian's Name (person completing this form)

Phone

Child's Full Name

Child's Nickname (or Name Used at School)

Child's Date of Birth (use format mm/dd/yyyy)

Allergies

Severe Medical Conditions

School Program

Grade/Class

PLEASE COMPLETE THIS SECTIOn FOR CHILDREN at CHARLOTTE JEWISH PRESCHOOL (CJP)

Half Day or Full Day

By initialing below, I confirm that my child is fully potty-trained. I understand that if my child is not fully potty-trained, he or she may be removed from any course(s) in which my child is registered with no refund. (Please enter initials.)

PEOPLE AUTHORIZED TO PICK UP CHILD FROM Levine JCC CLASSES

The following people are authorized to pick up my child from Levine JCC classes. These individuals may be required to show photo identification at the time of pickup. In order to gain entry to the Levine JCC facility, each individual must be in our computer system with a liability waiver and photo on file.

Parents do not need to be listed here. If only parents are allowed to pick up the child, please choose "None Allowed" in the first field.

If the person you list as an emergency contact is also authorized to pick up your child, please explicitly list that individual in this section.

Person Authorized to Pick up Child from Levine JCC Class (#1)

Person Authorized to Pick up Child from Levine JCC Class (#2)

Person Authorized to Pick up Child from Levine JCC Class (#3)

Person Authorized to Pick up Child from Levine JCC Class (#4)

Person Authorized to Pick up Child from Levine JCC Class (#5)

IN THE EVENT OF AN EMERGENCY

In case of emergency, I give the Levine JCC permission to secure treatment for my child. I understand that the Levine JCC will first attempt to contact me, then the emergency contact, then my child’s physician, in that order. However, if necessary, 911 will be called.

Emergency Contact (during time child at Levine JCC class)

Emergency Contact's Cell Phone

Emergency Contact Relationship to Child

Name of Child's Doctor

Doctor's Phone

Name of Child's Dentist

Dentist's Phone

Printed Name