Family to Family Application

    Family to Family 2022
    Family’s information

    1. Demographic Information

    a. Parents

    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

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

    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

    If you’re experiencing problem submitting this form online, you can download it in PDF format