*
Required
Immunization Information*
Wilshire Boulevard Temple is committed to ensure that all members of our community are protected and safeguarded from avoidable communicable diseases. We require that the families in our community maintain age-appropriate vaccinations, as recommended by the California Department of Public Health (CDPH), the American Academy of Pediatrics (AAP), and the Center for Disease Control (CDC). Please check here to indicate that you are in compliance with this policy.
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Child Information
Child First Name
*
required
Child Last Name
*
required
Preferred name/Nickname
Child Gender*
Male
Female
Child Birth Date
*
required
(mm/dd/yyyy)
Is this your child's first Baby & Me class?*
Yes
No
Are one or both parents Member(s) of Wilshire Boulevard Temple? *
Yes
No
Parent Information
Parent 1 First Name
*
required
Parent 1 Last Name
*
required
Relationship to child
*
required
Please Select…
Mother
Father
Grandmother
Grandfather
Guardian
Parent 1 Cell Number
*
required
Parent 1 Email
*
required
Address 1
*
required
Unit or Apartment No.
City
*
required
State
*
required
Zip
*
required
Add 2nd Parent Information?
Second Parent Information
Parent 2 First Name
*
required
Parent 2 Last Name
*
required
Relationship to child
*
required
Please Select…
Mother
Father
Grandmother
Grandfather
Guardian
Parent 2 Cell Number
*
required
Parent 2 Email
*
required
Address same as Parent 1?*
Yes
No
Address
*
required
Unit or Apartment No.
City
*
required
State
*
required
Zip
*
required
Please send a confirmation email to the address below*:
Please provide an email address where we can send a link to your current form.
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