2024-2025 Religious School Registration - Form

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 Address

Street Address Line 2

* City

* State

* Zip Code

Secondary Guardian Information

First Name

Last Name

Relationship to Student(s)

Home Phone

Cell Phone

Street Address

Street Address Line 2

City

State

Zip 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 Phone

Work Phone

Second Emergency Contact Information

* First Name

* Last Name

* Relationship to Student(s)

* Cell Phone

Home Phone

Work 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 Name

Student 1 Hebrew Name

* Student 1 Birthdate

* Student 1 Grade in Secular School in Fall 2024

Student 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 Name

Student 2 Hebrew Name

* Student 2 Birthdate

* Student 2 Grade in Secular School in Fall 2024

Student 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 Name

Student 3 Hebrew Name

* Student 3 Birthdate

* Student 3 Grade in Secular School in Fall 2024

Student 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 Name

Student 4 Hebrew Name

* Student 4 Birthdate

* Student 4 Grade in Secular School in Fall 2024

Student 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 Number

Name 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 below

By 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 Number

Work Phone

Authorized Person #2

* First Name

* Last Name

* Relationship to Student(s)

* Cell Number

* Home Number

Work Phone

Authorized Person #3

* First Name

* Last Name

* Relationship to Student(s)

* Cell Number

* Home Number

Work Phone

Authorized Person #4

* First Name

* Last Name

* Relationship to Student(s)

* Cell Number

* Home Number

Work Phone

Section G: School Fees

Are you a member?

MemberNot a MemberInterested in joining - someone will contact you

Number of children registered for Religious School (K-7)

Tuition for non-members:
Religious School = $500 per child

Number of children registered for Shalom Baby and/or Torah Treasures

Tuition for non-members:
Shalom Baby & Torah Treasures = $50 per child

Total number of children registered

Tuition for members is free.

Number of children registered for Shalom Baby and/or Torah Treasures

Tuition for non-members:
Shalom Baby & Torah Treasures = $50 per child

Number of children registered for Religious School (K-7)

Tuition for non-members:
Religious School = $500 per child

Total number of children registered

Tuition 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