Registration Form & Payment

How many students would you like to register?*

Student #1 - Name*

First Last

Student #1 - Grade*

Student #1 - Hebrew Name*

Student #1 - Public School Grade*

Student #1 - Date of Birth*

Student #2 - Name

First Last

Student #2 - Grade

Student #2 - Hebrew Name

Student #2 - Public School Grade

Student #2 - Date of Birth

Student #3 - Name

First Last

Student #3 - Grade

Student #3 - Hebrew Name

Student #3 - Public School Grade

Student #3 - Date of Birth

Student #4 - Name

First Last

Student #4 - Grade

Student #4 - Hebrew Name

Student #4 - Public School Grade

Student #4 - Date of Birth

Parent Information

Parent #1 - Name

Parent #2 - Name

Parent #1 - Cell Phone

Parent #2 - Cell Phone

Parent #1 - Work Phone

Parent #2 - Work Phone

Parent #1 - Email

Parent #2 - Email

If parents are divorced or separated, who is the custodial parent?

What is the best way to reach you during school hours, if needed?

Cell phone

Work phone

Emergency Contacts

In the event parents are unable to be contacted in case of illness or emergency, the following persons are to be notified:

Emergency Contact #1 - Name*

Emergency Contact #2 - Name

Emergency Contact #1 - Cell Phone*

Emergency Contact #2 - Cell Phone

Medical Information

Does one of the students have any allergies or medical conditions that we should be aware of?*

Yes

If yes, who?

If yes, please describe:

Does any member of your family have any allergies or medical conditions that could be put at risk because of food or any school activity?*

Yes

If yes, who?

If yes, please describe:

Hospital/Emergency Room preference

Call an ambulance?

Yes

Health Plan

Insurance Number

Does your child have any physical, vision, hearing, neurological, behavioral or other issues that impact learning?

If yes, the Director of Education will contact you to discuss your child's learning needs.

Yes

Is your child currently receiving special education services in his/her public or private school through an Individualized Education or 504 Plan?

If so, please submit a copy of the plan to the Educaton Director so we can meet your child’s academic needs to the best of our abilities within our classroom setting.

Yes

Would you like to receive a copy of the school's Special Education Policy?

Yes

Authorization for Medical Treatment - Parent/Guardian Signature

I hereby give permission to the Director of Education or Staff member in charge to take whatever steps deemed necessary to obtain emergency medical care, if warranted, for my child. In the case that emergency contacts are unavailable and emergency treatment is necessary, I hereby authorize a physician or such assistants to render emergency medical treatment to my son/daughter. I understand that I am responsible for any related expenses.

Your Involvement in the School

I am interested in volunteering in the Religious School.

Yes

Which classroom(s)?

I am interested in becoming a member of the Education Committee which meets monthly and discusses issues which pertain to the Religious School programs and curriculum.

Yes

Publishing Permissions

At Temple Beth Torah we are very proud of our students and their accomplishments. We highlight the kid’s activities and their accomplishments in many different ways using photographs, videos, and/or audio recordings. Please check next to each to give permission:

In-house power point presentation

Publishing in the class blog page or other Internet page

Class/Temple made movie posted to a private You Tube account

Local newspapers or other forms of publicity for TBT

Class/Temple made movie for in house viewing

School or Temple wide email newsletter

Electronic communication (i.e. Skype)

Display my child’s individual work and his/her contributions to group projects.

Exclusions

Computer and Internet Acceptable Use Policies

The Morris Nirenberg Religious School's information technology resources, including computer use and Internet access, are provided for educational purposes. Adherence to the following policy described here is necessary for continued access to the school's technological resources.

Violations of these rules may result in disciplinary action, including the loss of a student's privileges to use the school's information technology resources.

Supervision and Monitoring. Director of Education and teachers monitor the use of information technology resources to help ensure that uses are secure and in conformity with this policy. Administrators reserve the right to examine, use, and disclose any data found on the school's information networks in order to further the health, safety, discipline, or security of any student or other person, or to protect property. They may also use this information in disciplinary actions.

I acknowledge and understand the Computer and Internet Acceptable Use policy - Parent Signature:

Payment Information

Payment Method*

Pay by credit card

Pay by check

Please make your check payable to the synagogue and mail it to the synagogue office with a copy of the email receipt you will receive upon submission.

Please note that upon submission, you will be taken to PayPal's website in order to enter your credit card information.

Would you like to add an amount to cover the credit card convenience fee?

Yes - let me add a 2.2% + .30 contribution

Additional contribution to cover the credit card convenience fee

Price: $0.00

Total

Billing Information

Billing Name*

First Last

Billing Address*

Street Address City State ZIP Code

Billing Phone*

Billing Email*

CAPTCHA

Registration Form & Payment

Parent Information

Emergency Contacts

Medical Information

Your Involvement in the School

Publishing Permissions

Computer and Internet Acceptable Use Policies

Payment Information

Billing Information

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