Family to Family Application

Family to Family 2022
Family’s information

1. Demographic Information

a. Parents

Mother

Father

b. Occupation and profession

c. Marital StatusMarriedDivorcedSeparated

d. Custody Arrangements
SharedMother is a custodian parentFather is a custodian parent

e. Home address

f. Email(s)

g. Contact phone number(s)

h. Synagogue affiliation

2. Participating children

Child 1

Date of Birth Bar/Bat Mitzvah with the program: YesNo

Child 2

Date of Birth Bar/Bat Mitzvah with the program: YesNo

Other siblings, names and D.O.B.

3. Psychological Information

How would you describe your child?
a. Easily Engaged

b. Requires time to get to know other children to feel comfortable

c. Needs adult support to engage with other children

4. Medical Information

a. Does your child have the special medical conditions that we should be aware off?

b. Does your child take any prescribed medications?

c. Does your child have any allergies including allergies to pets?

5. Hobbies and/or family's interests

a. Children's hobbies & interests:

b. Activities:

c. Pets:

d. Any special or specific notes

6. Number of people traveling with the program:
M F Ch

7. Bar/bat Mitzvah Information