Chaverim New Student Payment Form 2021-2022

Student's First Name
Student's Last Name
Grade in Fall 2021
Email of parent or guardian

Chaverim full annual tuition $450. Please enter the amount you wish to pay today (deposit is necessary to complete registration):

  • $100 deposit - Balance $350 due no later than December 1, 2021
  • $100 deposit and 5 monthly payments of $70 - credit card must be kept on file at the JCC office call (707) 528-4222
  • $450 full tuition - no balance due
Amount of Payment (do not use $)
Type of credit card
Name on card
Credit card number


1st Responsible Parent/Guardian Name
1st Parent/Guardian Email
1st Parent/Guardian Cell Phone
2nd Responsible Parent/Guardian Name
2nd Parent/Guardian Email
2nd Parent/Guardian Cell Phone
Student Cell Phone
Do you have family/medical insurance?
Name of Policy Holder
Type of Insurance
Group or Policy Number
Name of Physician
Physician's Phone
Is student allergic to any foods or medications?
If yes, what?
Does student have any dietary restrictions?
Please describe and chronic or recurring illness or condition your child is affected by that would prevent him/her from participating in any activities or restrict their participation in such activities, and describe any restrictions that JCC staff should be aware of:
Emergency Contact Name & Relationship
Emergency Contact Phone
Emergency Contact Name & Relationship
Emergency Contact Phone
Emergency Contact Name & Relationship
Emergency Contact Phone


I hereby represent that I am the parent or legal guardian of the child named below. I understand and fully accept that there are risks of physical injury  involved in my child participating in Jewish Teen Program activities including but not limited to transportation to or from such activities. In consideration of my child being allowed to participate in Jewish Teen Program activities and programs, and on behalf of myself and my child, I hereby waive, release, relinquish and hold harmless, the Jewish Teen Program, Jewish Community Center, Sonoma County, Congregation Beth Ami, Congregation Ner Shalom, Congregation Shir Shalom, Congregation Shomrei Torah, B’nai Israel Jewish Center and each of their elected or appointed officers, directors, officials, employees, agents, insurers, volunteers and chaperones (the “released parties”) from any and all claims of loss, injury or damage, whether the result of active or passive negligence or fault which may hereafter occur, arising from or related to my child’s participation in or presence at Jewish Teen Program activities, including but not limited to transportation to or from such activities. By agreeing below I knowingly, voluntarily and expressly release and discharge the Released Parties named above from all such liability or claims even though such claims are not known at this time and do not presently exist. This release is knowingly and voluntarily entered into despite the language of Section 1542 of the California Civil Code which reads as follows: “A general release does not extend to claims which the creditor does not know or suspect to exist in his or her favor at the time of executing the release, which if known, by him or her must have materially affected his or her settlement with the debtor.”I hereby expressly waive and relinquish any rights or benefits which I or my child might have against the Released Parties under Section 1542 of the California Civil Code or any similar provision of statutory or non-statutory law of any jurisdiction to the fullest extent that I may lawfully waive all such rights and benefits pertaining to any of the subject matter of this Release.


Do you agree to the above terms and conditions?

 Authorization for Transportation to/from Activities and Use of Photographs

My child has permission to ride in any necessary transportation to or from Jewish Teen Program activities that are arranged by the Jewish Teen Program. I grant permission for my child to participate in all Jewish Teen Program activities except as may be specifically noted in the Medical Information above,

I hereby authorize the Jewish Teen Program to use photographs, videos, likenesses or testimonials of my child for Jewish Teen Program marketing purposes unless otherwise indicated in writing.

Do you agree to the above terms and conditions?