575 King Street, Port Chester NY 10573 • 914.939.1004 • info@ktionline.org

2016-2017 KTI HIGH SCHOOL Registration Form Please complete and submit to the KTI Office.

Student Information

Student’s Last Name Student’s First Name Male Female

Date of Birth ____/____/____

Student’s Hebrew Name Name of Public School 16-17 School Grade

Parent / Guardian Information

Mother’s Name Home Phone Cell Phone Work Phone

Home Address Email Address

Father’s Name Home Phone Cell Phone

Work Phone

Home Address (if different from above)

Email Address

Child’s Physician Physician’s Phone

Email address(es) to be used for all school correspondence (if different from above)

Emergency Contact If you cannot be reached in case of an emergency, give the names of local people to be notified: Name Relationship Phone Number

Cell: Home:

Cell: Home:

Please list the names of those who are authorized to pick your child up from school: 1._____________________________________ 2._______________________________________ (over)

PHOTO CONSENT FORM Student’s Name _________________________ I hereby grant permission, without reservation, to Congregation KTI to take photographs and to make recordings of me/my child, and to use them in original or modified form in all media now

or hereafter known, with or without my name or information about me, for the promotion, public education, and/or fundraising activities Congregation KTI. I understand and agree that I am

entitled to receive no compensation for the above.

I agree that Congregation KTI has rights, tangible and intangible, in the above mentioned photographs and recordings, with full power of disposition.

YES ____

NO ____

Signature My signature confirms that the above information is accurate, that the guidelines and procedures of the KTI High School will be adhered to, and that I understand it is my responsibility to keep the above information current. Signature of Parent:__________________________________ Date:____________