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Section A: Family Contact Information ** Please note if student(s) lives in a divorced/separated/never married household, the Primary Guardian will need to ask the School office for the Custody Guidelines Supplement, which needs to be returned with the Registration.** Primary Guardian Information * First Name * Last Name * Relationship to Student(s)* Email * Phone * Cell Phone* Street AddressStreet Address Line 2* City* State--Select State--AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming* Zip Code Secondary Guardian Information First NameLast NameRelationship to Student(s)Email Home Phone Cell PhoneStreet AddressStreet Address Line 2 CityStateZip Code Section B: Emergency Contact Information - These should be people other than the parents/guardians. First Emergency Contact Information * First Name* Last Name* Relationship to Student(s)* Cell Phone Home PhoneWork Phone Second Emergency Contact Information * First Name* Last Name* Relationship to Student(s)* Cell Phone Home PhoneWork Phone Section C: Student Enrollment Information * How many children are being enrolled for the 2023-2024 year?Please Select One1 Child2 Children3 Children4 ChildrenTUITION FEES Non-Members: $50 for Shalom Baby & Torah Treasures, $500 for Religious School Members: Free Student 1 Information * Student 1 First Name* Student 1 Last NameStudent 1 Hebrew Name* Student 1 Birthdate* Student 1 Hebrew School Grade Please Select OneShalom BabyTorah TreasuresKindergarten1st Grade2nd Grade3rd Grade4th Grade5th Grade6th Grade7th Grade* Student 1 Grade in Secular School in Fall 2024Student 1 - Does your child have any special learning needs or receive any special services in public/private school?YesNo**If yes, please make an appointment to meet with the Rabbi and your child’s teacher(s) to discuss your child’s educational needs.Student 1 - Does your child have an IEP or 504 plan?YesNo**If yes, please submit the most recent version with the Registration and make an appointment to meet with the Rabbi and your child’s teacher(s) to discuss your child’s educational needs.Student 1 - Does your child have any allergies? If yes, please list here: Student 2 Information * Student 2 First Name* Student 2 Last NameStudent 2 Hebrew Name* Student 2 Birthdate* Student 2 Hebrew School Grade Please Select OneShalom BabyTorah TreasuresKindergarten1st Grade2nd Grade3rd Grade4th Grade5th Grade6th Grade7th Grade* Student 2 Grade in Secular School in Fall 2024Student 2 - Does your child have any special learning needs or receive any special services in public/private school?YesNo**If yes, please make an appointment to meet with the Rabbi and your child’s teacher(s) to discuss your child’s educational needs.Student 2 - Does your child have an IEP or 504 plan?YesNo**If yes, please submit the most recent version with the Registration and make an appointment to meet with the Rabbi and your child’s teacher(s) to discuss your child’s educational needs.Student 2 - Does your child have any allergies? If yes, please list here: Student 3 Information * Student 3 First Name* Student 3 Last NameStudent 3 Hebrew Name* Student 3 Birthdate* Student 3 Hebrew School GradePlease Select OneShalom BabyTorah TreasuresKindergarten1st Grade2nd Grade3rd Grade4th Grade5th Grade6th Grade7th Grade* Student 3 Grade in Secular School in Fall 2024Student 3 - Does your child have any special learning needs or receive any special services in public/private school?YesNo**If yes, please make an appointment to meet with the Rabbi and your child’s teacher(s) to discuss your child’s educational needs.Student 3 - Does your child have an IEP or 504 plan?YesNo**If yes, please submit the most recent version with the Registration and make an appointment to meet with the Rabbi and your child’s teacher(s) to discuss your child’s educational needs.Student 3 - Does your child have any allergies? If yes, please list here: Student 4 Information * Student 4 First Name* Student 4 Last NameStudent 4 Hebrew Name* Student 4 Birthdate* Student 4 Hebrew School Grade Please Select OneShalom BabyTorah TreasuresKindergarten1st Grade2nd Grade3rd Grade4th Grade5th Grade6th Grade7th Grade* Student 4 Grade in Secular School in Fall 2024Student 4 - Does your child have any special learning needs or receive any special services in public/private school?YesNo**If yes, please make an appointment to meet with the Rabbi and your child’s teacher(s) to discuss your child’s educational needs.Student 4 - Does your child have an IEP or 504 plan?YesNo**If yes, please submit the most recent version with the Registration and make an appointment to meet with the Rabbi and your child’s teacher(s) to discuss your child’s educational needs.Student 4 - Does your child have any allergies? If yes, please list here: Section D: Family Doctor/Health Insurance Pediatrician's Name and Phone NumberName of Insurance Company, Policy ID#, Policy Group # Front of Insurance Card Upload a picture of the front of your insurance card. Back of Insurance Card Upload a picture of the back of your insurance card. Section E: Publication of Child(ren)'s Picture and/or Work You may publish my child(ren)’s photo or work. I, as parent or guardian of the child(ren), understand that his/her artwork, writing and/or photo may be published on the Internet and/or local publications. No home address or telephone number will appear with my child(ren)’s picture, name, or work. I understand that my child(ren) will retain all copyright and other intellectual property rights to such work. * Media Release: Enter your name belowBy typing my name, I confirm I have read, understand and agree to the above. Section F: Child(ren) Pick-Up Authorization Your child(ren) will only be permitted to leave with the adults listed below. Please list all authorized persons, even if authorized persons all live in the same household. Child(ren) will only be released to an authorized person who comes into the synagogue. Please update this form with the religious school office as needed. Authorized Person #1 * First Name* Last Name* Relationship to Student(s)* Cell Number* Home NumberWork Phone Authorized Person #2 * First Name* Last Name* Relationship to Student(s)* Cell Number* Home NumberWork Phone Authorized Person #3 * First Name* Last Name* Relationship to Student(s)* Cell Number* Home NumberWork Phone Authorized Person #4 * First Name* Last Name* Relationship to Student(s)* Cell Number* Home NumberWork Phone Section G: School Fees Are you a member? MemberNot a MemberInterested in joining - someone will contact youNumber of children registered for Religious School (K-7)01234Tuition for non-members: Religious School = $500 per childNumber of children registered for Shalom Baby and/or Torah Treasures01234Tuition for non-members: Shalom Baby & Torah Treasures = $50 per child Total number of children registered 01234Tuition for members is free. Number of children registered for Shalom Baby and/or Torah Treasures01234Tuition for non-members: Shalom Baby & Torah Treasures = $50 per child Number of children registered for Religious School (K-7)01234Tuition for non-members: Religious School = $500 per childTotal number of children registered 01234Tuition for members is free. PTO Fee - Based on Grade Family PTO Fee Registered for Grades K-7Only registered for Shalom Baby or Torah Treasures$65 per family Bar/Bat Mitzvah Fee - Payment due at start of training - $900 Will be billed separately Total Amount Due Mon, February 10 2025 12 Shevat 5785
Please verify reCaptcha before submitting the form.
You may publish my child(ren)’s photo or work. I, as parent or guardian of the child(ren), understand that his/her artwork, writing and/or photo may be published on the Internet and/or local publications. No home address or telephone number will appear with my child(ren)’s picture, name, or work. I understand that my child(ren) will retain all copyright and other intellectual property rights to such work.
