Yahalom NY Chanukah Party! - Agudath Israel of America

Family Name(Required)

Email(Required)

Name of child/ children with special needs.(Required)

DOB of child/ children with special needs(Required)

Diagnosis of child/ children with special needs (all information is kept confidential)(Required)

Which location are you planning to attend?(Required)

Monsey - December 10th 7:30 PM -10:30 PM

5 Towns - December 11th 4 PM - 7 PM

How many adults will be attending?(Required)

How many children will be attending?(Required)

Special needs or supports your child may need?(Required)

(allergies, low noise, low lighting, etc)

Would your child with special needs benefit from a 1:1 counselor?(Required)

(staff permitting - we can't guarantee that we can do this but we will definitely try)

Yes

Comments?