Religious School Registration 2019

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Tuesday, July 16, 2019 • 13 Tammuz 5779

All Day for 321 DaysTemple Sholom

Temple Sholom Religious School is back for 2019-20
and we are ready to rock your world!

Classes Start Sunday September 8th

9:15 - 11:45 for Pre-K - 2nd Grade
9:15 - 12:15 for 3rd - Post Bnai Mitzvah

To enroll your students in Religious School, please complete the registration form below.

Register

Registration Form For Religious School
Pre-Kindergarten (age 4) - 8th Grade

* How many children are you registering for Religious School?

Please Select OneOneTwoThreeIf you are registering more than 3 children, please call the Temple Office at 513-791-1330

First Child:

Name of First Child

First Child - Date of Birth

First child - Please enter your child's Hebrew name (if known):

Use of Images in the Media

Please Select OneYes, I do hereby consent and agree with the statement below and allow the use of images of myself or my child in the media.No, I do not consent to the use of images of myself or my child in the media.

Temple Sholom Use of Images in the Media:

Temple Sholom, its employees, or agents have the right to take photographs, videotape, or digital recordings ("Images") of me or my child and to use these in any and all media exclusively for the purpose of communicating the educational activities of the Temple. I do hereby release to Temple Sholom, its agents, and employees all rights to exhibit this work in print and electronic form publicly or privately. I wave any rights, claims, or interest I may have to control the use of my image in whatever media used. Child last names will not be used with media images.

Parent/Legal Guardian Name:

Please enter the name of the parent or legal guardian who completed the "Use of Images in the Media" form:

Consent for Emergency Medical Treatment
PART I OR II MUST BE COMPLETED BELOW:

PART I - Providing Consent for Emergency Medical Treatment

PART I: Yes, I give my consent for emergency medical treatment of my child as outlined below:

IF REASONABLE ATTEMPTS TO REACH ME FAIL, I HEREBY GIVE MY CONSENT FOR:
1. The administration of any treatment deemed necessary by the medical professionals I have listed as my child's physician in the "emergency contacts" section of this enrollment form.
2. If my designated medical professional is not available, by another medical professional; and
3. The transfer of my child to any hospital reasonably accessible.

Parent/Legal Guardian Name:

Please enter the name of the parent or legal guardian who completed Part I - Consent for Emergency Medical Treatment

PART II - Consent is NOT given for Emergency Medical Treatment

PART II: NO, I do NOT give my consent for emergency medical treatment of my child.

Parent/Legal Guardian Name:

Please enter the name of the parent or legal guardian who completed Part II - Consent is not given for emergency medical treatment.

Parent/Guardian Information for the first child:

* Parent/Guardian 1: First Name

* Parent/Guardian 1: Last Name

* Relationship of Parent/Guardian 1 to the child:

* Street Address of Parent/Guardian 1

Email address for Parent/Guardian 1:

Home phone for Parent/Guardian 1:

Cell phone for Parent/Guardian 1:

Which is the best phone number to contact Parent/Guardian 1?

Please Select OneHome phoneCell phone

Parent/Guardian 2: First Name

Parent/Guardian 2: Last Name

Relationship of Parent/Guardian 2 to the child:

Street Address of Parent/Guardian 2

Email address for Parent/Guardian 2:

Home phone for Parent/Guardian 2:

Cell phone for Parent/Guardian 2:

Which is the best phone number to contact Parent/Guardian 2?

Please Select OneHome phoneCell phone

Additional Information about the first child:

* Does this child have an IEP, 504 Plan, or other academic plan in place in their secular school?

Please Select OneYesNo

* If yes, please provide information on your child's academic plan:

* Is there anything we need to know or be sensitive to concerning the emotional or behavioral well-being of this child?

Please Select OneYesNo

If yes, please provide information on your child's emotional or behavioral well-being.

* Does this child have any food allergies?

Please Select OneYesNo

if yes, please provide specific information on your child's food allergies:

If your child has a food allergy, we require that an unopened EpiPen pack along with instructions and contact phone numbers be provided to the Temple Sholom office in a plastic zip-lock bag.

* Does this child have any other health concerns that could affect them at Religious School?

Please Select OneYesNo

If yes, please provide specific information on your child's health concerns.

If there is a chance that your child will need medication, such as an inhaler for asthma, during school hours, please provide the Temple Sholom office with an unopened package of the medication, instructions and contact phone numbers in a plastic zip-lock bag.

Please share any other information that will help us create a safe, effective, and meaningful educational experience for your child:

Emergency Contact Information for the first child:

First Child - Name of child's Primary Physician

First Child - Phone number of child's Primary Physician

First Child - Name of child's Dentist

First Child - Phone number of child's Dentist

First Child - Emergency Contact 1

Please enter the name of an emergency contact who is not a Parent/Guardian of the child.

First Child - Relationship to Emergency Contact 1

For example: Aunt, Uncle, Cousin, or friend

First Child - Emergency Contact 1 Phone Number

First Child - Emergency Contact 2

Please enter the name of an emergency contact who is not a Parent/Guardian of the child.

First Child - Relationship to Emergency Contact 2

For example: Aunt, Uncle, Cousin, or friend

First Child - Emergency Contact 2 Phone Number

Second Child:

Second Child - Name

Second child - Date of Birth

Second child - Please enter your child's Hebrew name (if known):

Use of Images in the Media - Second Child

Please Select OneYes I do hereby consent and agree with the statement below and allow the use of images of myself or my child in the media.No I do not consent to the use of images of myself or my child in the media.Temple Sholom Use of Images in the Media:

Temple Sholom, its employees, or agents have the right to take photographs, videotape, or digital recordings ("Images") of me or my child and to use these in any and all media exclusively for the purpose of communicating the educational activities of the Temple. I do hereby release to Temple Sholom, its agents, and employees all rights to exhibit this work in print and electronic form publicly or privately. I wave any rights, claims, or interest I may have to control the use of my image in whatever media used. Child last names will not be used with media images.

Parent/Legal Guardian Name:

Please enter the name of the parent or legal guardian who completed the "Use of Images in the Media" form for the 2nd child.

Consent for Emergency Medical Treatment for the Second Child
PART I OR II MUST BE COMPLETED BELOW:

PART I - Providing Consent for Emergency Medical Treatment

PART I: Yes, I give my consent for emergency medical treatment of my child as outlined below:

Parent/Legal Guardian Name:

Please enter the name of the parent or legal guardian who completed Part I - Consent for Emergency Medical Treatment for the 2nd child.

PART II - Consent is NOT given for Emergency Medical Treatment

PART II: NO, I do NOT give my consent for emergency medical treatment of my child.

Parent/Legal Guardian Name:

Please enter the name of the parent or legal guardian who completed Part II - Consent is not given for emergency medical treatment of the 2nd child.

Parent/Guardian Information for the second child:

* Are the Parents/Guardians of the second child the same as for the first child?

Please Select OneYesNo

* Second Child - Parent/Guardian 1: First Name

* Second Child - Parent/Guardian 1: Last Name

* Second Child - Relationship of Parent/Guardian 1 to the child:

* Second Child - Street Address of Parent/Guardian 1

Second Child - Email address for Parent/Guardian 1:

Second Child - Home phone for Parent/Guardian 1:

Second Child - Cell phone for Parent/Guardian 1:

Second Child - Which is the best phone number to contact Parent/Guardian 1?

Please Select OneHome phoneCell phone

Second Child - Parent/Guardian 2: First Name

Second Child - Parent/Guardian 2: Last Name

Second Child - Relationship of Parent/Guardian 2 to the child:

Second Child - Street Address of Parent/Guardian 2

Second Child - Email address for Parent/Guardian 2:

Second Child - Home phone for Parent/Guardian 2:

Second Child - Cell phone for Parent/Guardian 2:

Second Child - Which is the best phone number to contact Parent/Guardian 2?

Please Select OneHome phoneCell phone

Additional Information about the second child:

* Does your 2nd child have an IEP, 504 Plan, or other academic plan in place in their secular school?

Please Select OneYesNo

* If yes, please provide information on your 2nd child's academic plan:

* Is there anything we need to know or be sensitive to concerning the emotional or behavioral well-being of this child?

Please Select OneYesNo

If yes, please provide information on your 2nd child's emotional or behavioral well-being.

* Does your 2nd child have any food allergies?

Please Select OneYesNo

if yes, please provide specific information on your 2nd child's food allergies:

If your child has a food allergy, we require that an unopened EpiPen pack along with instructions and contact phone numbers be provided to the Temple Sholom office in a plastic zip-lock bag.

* Does your 2nd child have any other health concerns that could affect them at Religious School?

Please Select OneYesNo

If yes, please provide specific information on your 2nd child's health concerns.

Please share any other information that will help us create a safe, effective, and meaningful educational experience for your 2nd child:

Emergency Contact Information for the second child:

* Is ALL of the Emergency Contact information for the second child the same as for the first child?

Please Select OneYesNoThis includes: Primary Physician, Dentist, and 2 non-parent/guardian emergency contacts.

Second Child - Name of child's Primary Physician

Second Child - Phone number of child's Primary Physician

Second Child - Name of child's Dentist

Second Child - Phone number of child's Dentist

Second Child - Emergency Contact 1

Please enter the name of an emergency contact who is not a Parent/Guardian of the child.

Second Child - Relationship to Emergency Contact 1

For example: Aunt, Uncle, Cousin, or friend

Second Child - Emergency Contact 1 Phone Number

Second Child - Emergency Contact 2

Please enter the name of an emergency contact who is not a Parent/Guardian of the child.

Second Child - Relationship to Emergency Contact 2

For example: Aunt, Uncle, Cousin, or friend

Second Child - Emergency Contact 2 Phone Number

Third Child:

Third Child - Name

Third Child - Date of Birth

Third Child - Please enter your child's Hebrew name (if known):

Use of Images in the Media - Third Child

Temple Sholom Use of Images in the Media:

Temple Sholom, its employees, or agents have the right to take photographs, videotape, or digital recordings ("Images") of me or my child and to use these in any and all media exclusively for the purpose of communicating the educational activities of the Temple. I do hereby release to Temple Sholom, its agents, and employees all rights to exhibit this work in print and electronic form publicly or privately. I wave any rights, claims, or interest I may have to control the use of my image in whatever media used. Child last names will not be used with media images.

Parent/Legal Guardian Name:

Please enter the name of the parent or legal guardian who completed the "use of Imges in the Media" form for the 3rd child.

Consent for Emergency Medical Treatment for the Third Child
PART I OR II MUST BE COMPLETED BELOW:

PART I - Providing Consent for Emergency Medical Treatment

PART I: Yes, I give my consent for emergency medical treatment of my child as outlined below:

Parent/Legal Guardian Name:

Please enter the name of the parent or legal guardian who completed Part 1 - Consent for Emergency Medical Treatment for the 3rd child.

Part II - Consent is NOT given for Emergency Medical Treatment

Part II: No, I do NOT give my consent for emergency medical treatment of my child.

Parent/Legal Guardian Name:

Please enter the name of the parent or legal guardian who completed Part II - Consent is not given for emergency medical treatment of the 3rd child.

Parent/Guardian Information for the third child:

* Are the Parents/Guardians of the third child the same as for the first or second child?

Please Select OneYesNo

* Please choose from below:

Please Select OneParents/Guardians are the same as the First ChildParents/Guardians are the same as the Second Child

* Third Child - Parent/Guardian 1: First Name

* Third Child - Parent/Guardian 1: Last Name

* Third Child - Relationship of Parent/Guardian 1 to the child:

* Third Child - Street Address of Parent/Guardian 1

Third Child - Email address for Parent/Guardian 1:

Third Child - Home phone for Parent/Guardian 1:

Third Child - Cell phone for Parent/Guardian 1:

Third Child - Which is the best phone number to contact Parent/Guardian 1?

Please Select OneHome phoneCell phone

Third Child - Parent/Guardian 2: First Name

Third Child - Parent/Guardian 2: Last Name

* Third Child - Relationship of Parent/Guardian 2 to the child:

Third Child - Street Address of Parent/Guardian 2

Third Child - Email address for Parent/Guardian 2:

Third Child - Home phone for Parent/Guardian 2:

Third Child - Cell phone for Parent/Guardian 2:

Third Child - Which is the best phone number to contact Parent/Guardian 2?

Please Select OneHome phoneCell phone

Additional Information about the third child:

* Does your 3rd child have an IEP, 504 Plan, or other academic plan in place in their secular school?

Please Select OneYesNo

* If yes, please provide information on your 3rd child's academic plan:

* Is there anything we need to know or be sensitive to concerning the emotional or behavioral well-being of this child?

Please Select OneYesNo

If yes, please provide information on your 3rd child's emotional or behavioral well-being.

* Does your 3rd child have any food allergies?

Please Select OneYesNo

if yes, please provide specific information on your 3rd child's food allergies:

If your child has a food allergy, we require that an unopened EpiPen pack along with instructions and contact phone numbers be provided to the Temple Sholom office in a plastic zip-lock bag.

* Does your 3rd child have any other health concerns that could affect them at Religious School?

Please Select OneYesNo

If yes, please provide specific information on your 3rd child's health concerns.

Please share any other information that will help us create a safe, effective, and meaningful educational experience for your 3rd child:

Emergency Contact Information for the third child:

* Is ALL of the Emergency Contact information for the third child the same as for the first or second child?

Please Select OneYesNoOnly choose "Yes" if ALL of the information (Primary Physician, Dentist, and both Emergency Contacts) are exactly the same.

* Please choose from below:

Please Select Oneemergency Contact Information is the same as the First ChildEmergency Contact Information is the same as the Second Child

Third Child - Name of child's Primary Physician

Third Child - Phone number of child's Primary Physician

Third Child - Name of child's Dentist

Third Child - Phone number of child's Dentist

Third Child - Emergency Contact 1

Please enter the name of an emergency contact who is not a Parent/Guardian of the child.

Third Child - Relationship to Emergency Contact 1

For example: Aunt, Uncle, Cousin, or friend

Third Child - Emergency Contact 1 Phone Number

Third Child - Emergency Contact 2

Please enter the name of an emergency contact who is not a Parent/Guardian of the child.

Third Child - Relationship to Emergency Contact 2

For example: Aunt, Uncle, Cousin, or friend

Third Child - Emergency Contact 2 Phone Number

Tuition Payment

Total Tuition for all children:

The above amount is the total for Religious School Tuition for all children registered

I will pay my tuition as follows:

Please Select OneI will pay by credit card - please charge the card linked to my ShulCloud AccountI will pay by credit card - I will call the office (513.791.1330) to provide the card informationl will pay by check - I will send my check to the Temple OfficePlease charge my ShulCloud accountMy family would benefit from a scholarship

Let us know what method you will use to pay your tuition. Finances never stand in the way of your child's Religious Education at Temple Sholom. If you would benefit from a scholarship, please let us know by checking the Scholarship option above.

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Sun, December 8 2019
10 Kislev 5780

Sun, December 8 2019 10 Kislev 5780