Clone of Hebrew School Registration Form

The Religious School of Congregation B'nai Tikvah
K-12th Grade Registration

Please submit information no later than August 21, 2015. If you need a paper form, please contact Sue Brin: sbrin@bnaitikvah.net

Please note the extensive nature of our form. We urge you to complete all fields so that in case of emergency we can best care for your child. Unfortunately, we will have to return your form to you or contact you for more information if any item is incomplete. Thank you for your attention to this matter.
Student Information
Student Name 1

First Name Last Name
Birth Date

Month Day Year
Male or Female?

Male Female
Hebrew Name (transliterated)
Secular School Grade 15-16
Secular School
Friend Request 1 (optional)
Friend Request 2 (optional)
Student Name 2

First Name Last Name
Birth Date

Month Day Year
Male or Female?

Male Female
Hebrew Name (transliterated)
Secular School Grade 15-16
Secular School
Friend Request 1 (optional)
Friend Request 2 (optional)
Student Name 3

First Name Last Name
Birth Date

Month Day Year
Male or Female?

Male Female
Hebrew Name (transliterated)
Secular School Grade 15-16
Secular School
Friend Request 1 (optional)
Friend Request 2 (optional)
Parent/Guardian Information
Parent/Guardian 1

First Name Last Name
Address 1

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
E-mail 1
Home Phone 1

Area Code Phone Number
Work Phone 1

Area Code Phone Number
Cell Phone 1

Area Code Phone Number
Parent/Guardian 2

First Name Last Name
Address 2

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
E-mail 2
Home Phone 2

Area Code Phone Number
Work Phone 2

Area Code Phone Number
Cell Phone 2

Area Code Phone Number
Child residing with
Emergency Information
Physician's Name
Phone Number

Area Code Phone Number
Insurance Carrier
Policy #
If Parent or Guardian cannot be contacted:

First Name Last Name
Relationship
Home Phone

Area Code Phone Number
Cell Phone

Area Code Phone Number
Work Phone

Area Code Phone Number
Emergency Medical Treatment
In case of emergency, we hereby authorize (by our indication below) the Director of Lifelong Learning, Administrator, or Teacher to call our physician or take our child/ren to the hospital to receive appropriate emergency treatment. *

We Authorize We DO NOT Authorize
Field Trip
I hereby authorize my child/ren to participate in field trips and programs with his/her class. I agree to hold our congregation (including its board, officers, staff and volunteers) harmless from any and all claims that may arise out of his/her participation in school trips and programs. Note: Parents will receive advance notice about field trips held throughout the year. *

We Authorize We DO NOT Authorize
Photograph/Video Release
I hereby give permission to use the name and likeness, including photographs/videos of the minor(s) named above, for publicity, promotion, news release, videos and web use of our congregation and our school. This permission might also apply to written compositions or visual art created by the minor if selected for such use. *

We give permission We DO NOT give permission
We can serve your child best if we know about your child

(All information you share will be kept strictly confidential)
Does your child/ren have any medical concerns (allergies, medications, etc.)? Please be specific.
Does your child/ren have any learning issues that we should be aware of (ADD, ADHD, speech and language, dyslexia, developmental delays, etc.)?
Is there anything else you think we should know about your child/ren (temperament, strengths, friends, etc.)?
Does your child/ren have an IEP (Individual Education Plan) or 504 plan at his/her secular school?

Yes No
Volunteering
Would you like to be contacted about volunteer opportunities?

Yes No
Primary Contact
Reintroduction to Judaism Parent Class (Optional)
These active and accessible classes cover Judaism’s biggest and most inspiring ideas as well as the nuts-and-bolts of daily Jewish living. Starting in the fall we’ll cover history, holidays, practices, text, values and more. Whether you’re back to learning after a long hiatus or you’re just looking for a deeper understanding of our heritage, we could all use a bit of a refresher. This program is intended for Jews from all walks of life: from parents who had a Jewish day school education to those whose strongest connection was the annual box of matzah on the kitchen counter. This class meets twice monthly on Sundays from 10-10:45.
Parent 1

First Name Last Name
Parent 2

First Name Last Name
Once you have completed this form, please click on the submit button below. Please expect to be contacted by our bookkeeper about school tuition payment. Todah Rabbah!
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The Religious School of Congregation B'nai Tikvah

Student Information

Parent/Guardian Information

Emergency Information

Emergency Medical Treatment

Field Trip

Photograph/Video Release

We can serve your child best if we know about your child

Volunteering

Reintroduction to Judaism Parent Class (Optional)

Once you have completed this form, please click on the submit button below. Please expect to be contacted by our bookkeeper about school tuition payment. Todah Rabbah!