How many children are enrolling?* Choose One Two Three Four
Student #1 Information Child's Name*
First
Last
Date of Birth*
MM slash DD slash YYYY
Gender* Choose Male Female Other
Gender - Other* Please specify this student's preferred gender identity.
Name of Secular School*
Secular School Grade* For the 2021-2022 school year
Grade Pre-K K 1st Grade 2nd Grade 3rd Grade 4th Grade 5th Grade 6th Grade 7th Grade 8th Grade 9th Grade 10th Grade 11th Grade 12th Grade
Religious School Grade* For the 2021-2022 school year
Grade Pre-K K 1st Grade 2nd Grade 3rd Grade 4th Grade 5th Grade 6th Grade 7th Grade 8th Grade 9th Grade
Confidential Information
Is your child in any special learning environment in secular school?
Does your child have any behavioral issues about which the Religious School should be aware?
Is there any situation at home about which the Religious School should be aware?
Is there any other information that you feel the Religious School should know in order to best meet your child’s needs?
Please write your comments in the box below:
Allergies & Medications Please describe any allergies or medications needed with dosage and timing:
Class Friend Request Please list one child with whom your child would like to be in class.
Note: We might not be able to honor classmate requests received after Monday, August 9, 2021.
Please indicate your choice of program for the 2021-2022 school year:* Student #2 Information Child's Name*
First
Last
Date of Birth*
MM slash DD slash YYYY
Gender* Choose Male Female Other
Gender - Other* Please specify this student's preferred gender identity.
Name of Secular School*
Secular School Grade* For the 2021-2022 school year
Grade Pre-K K 1st Grade 2nd Grade 3rd Grade 4th Grade 5th Grade 6th Grade 7th Grade 8th Grade 9th Grade 10th Grade 11th Grade 12th Grade
Religious School Grade* For the 2021-2022 school year
Grade Pre-K K 1st Grade 2nd Grade 3rd Grade 4th Grade 5th Grade 6th Grade 7th Grade 8th Grade 9th Grade
Confidential Information
Is your child in any special learning environment in secular school?
Does your child have any behavioral issues about which the Religious School should be aware?
Is there any situation at home about which the Religious School should be aware?
Is there any other information that you feel the Religious School should know in order to best meet your child’s needs?
Please write your comments in the box below:
Class Friend Request Please list one child with whom your child would like to be in class.
Note: We might not be able to honor classmate requests received after Monday, August 9, 2021.
Please indicate your choice of program for the 2021-2022 school year:* Student #3 Information Child's Name*
First
Last
Date of Birth*
MM slash DD slash YYYY
Gender* Choose Male Female Other
Gender - Other* Please specify this student's preferred gender identity.
Name of Secular School*
Secular School Grade* For the 2021-2022 school year
Grade Pre-K K 1st Grade 2nd Grade 3rd Grade 4th Grade 5th Grade 6th Grade 7th Grade 8th Grade 9th Grade 10th Grade 11th Grade 12th Grade
Religious School Grade* For the 2021-2022 school year
Grade Pre-K K 1st Grade 2nd Grade 3rd Grade 4th Grade 5th Grade 6th Grade 7th Grade 8th Grade 9th Grade
Confidential Information
Is your child in any special learning environment in secular school?
Does your child have any behavioral issues about which the Religious School should be aware?
Is there any situation at home about which the Religious School should be aware?
Is there any other information that you feel the Religious School should know in order to best meet your child’s needs?
Please write your comments in the box below:
Class Friend Request Please list one child with whom your child would like to be in class.
Note: We might not be able to honor classmate requests received after Monday, August 9, 2021.
Please indicate your choice of program for the 2021-2022 school year:* Student #4 Information Child's Name*
First
Last
Date of Birth*
MM slash DD slash YYYY
Gender* Choose Male Female Other
Gender - Other* Please specify this student's preferred gender identity.
Name of Secular School*
Secular School Grade* For the 2021-2022 school year
Grade Pre-K K 1st Grade 2nd Grade 3rd Grade 4th Grade 5th Grade 6th Grade 7th Grade 8th Grade 9th Grade 10th Grade 11th Grade 12th Grade
Religious School Grade* For the 2021-2022 school year
Grade Pre-K K 1st Grade 2nd Grade 3rd Grade 4th Grade 5th Grade 6th Grade 7th Grade 8th Grade 9th Grade
Confidential Information
Is your child in any special learning environment in secular school?
Does your child have any behavioral issues about which the Religious School should be aware?
Is there any situation at home about which the Religious School should be aware?
Is there any other information that you feel the Religious School should know in order to best meet your child’s needs?
Please write your comments in the box below:
Class Friend Request Please list one child with whom your child would like to be in class.
Note: We might not be able to honor classmate requests received after Monday, August 9, 2021.
Please indicate your choice of program for the 2021-2022 school year:* Parent/Guardian Contact Information Parent/Guardian 1 Name*
First
Last
Parent/Guardian 1 Email* This parent/guardian will receive an automatically-generated email confirming enrollment after this form is submitted.
Parent/Guardian 1 Phone*
Mailing Address*
Would you like to add a second parent or guardian?* Parent/Guardian #2 Contact Information Parent/Guardian 2 Name*
First
Last
Parent/Guardian 2 Email*
Parent/Guardian 2 Phone*
Does this parent/guardian have a different mailing address?* It is our policy to mail report cards and other pertinent information to both parents unless there is a court order to the contrary.
Parent/Guardian 2 Mailing Address*
Emergency Contact Information Please let us know who we should contact in case we are unable to reach either parent.
Name* (Emergency contact should be someone other than a parent or guardian.)
First
Last
Relationship to child(ren)*
Phone*
Would you like to add another emergency contact person?* Name*
First
Last
Relationship to child(ren)*
Phone*
Release Forms Name of Insurance Company
Insurance Policy Number
Name of Child(ren)'s Physician
Phone
Name of Child(ren)'s Dentist
Phone
Medical* I empower the teachers and advisors of Congregation Schaarai Zedek, Inc., or their agents to act for me in accordance with their best judgment in an emergency. I hereby give permission to the physician selected by the teacher or advisor to hospitalize, secure proper treatment for, and to order injection, anesthesia or surgery for my child(ren).
I agree.
Transportation* In consideration for transporting my/our child(ren) for any Congregation Schaarai Zedek Religious School (“Religious School”) activity and/or event, I/we, individually and on behalf of my/our child, hereby knowingly and freely waive any and all causes of action including any and all claims or causes of action arising from or related to any negligence on the part of Congregation Schaarai Zedek, Inc., its Board of Trustees, its/their agents, employees, members, representatives, successors and assigns and any claims of liability arising from such transportation as referenced in this Release, which my/our child and I/we may have or acquire against Congregation Schaarai Zedek, Inc., its Board of Trustees, its/their agents, employees, members, representatives, successors and assigns.
I agree.
Religious School Activities and/or Events* Separate and apart from the undersigned’s intent to release Congregation Schaarai Zedek, Inc., its Board of Trustees, its/their agents, employees, members, representatives, successors and assigns from all liability arising from transportation, and in consideration for my/our child being allowed to take part in Religious School activities and/or events, I/we for my/our child, our heirs, executors and administrators, legal representatives and assigns, release and forever discharge Congregation Schaarai Zedek, Inc., its Board of Trustees, its/their agents, employees, members, representatives, successors and assigns of all liabilities, claims, actions, damages, costs or expenses which I/we may have against them, including all claims, actions, damages, costs or expenses which my/our child may have against them arising from or in any way connected to my/our child’s participation in Religious School activities and/or events, including injuries which may be suffered before, during or after the Religious School activity and/or event, as a result of alleged negligence on the part of Congregation Schaarai Zedek, Inc., its Board of Trustees, its/their agents, employees, members, representatives, successors and assigns.
I agree.
Signature* By typing my name, I confirm I have read, understand and agree to the above.
Payment Are you a current temple member of Congregation Schaarai Zedek?* Temple Member Religious School Fee* How many children are you enrolling?
Choose Member - One Child Member - Two Children Member - Three Children Member - Four Children
Non-Member Religious School Fee* How many children are you enrolling?
Choose Non-Member - One Child Non-Member - Two Children Non-Member - Three Children Non-Member - Four Children
Payment* If you would like to pay the total amount today, you will be taken to a secure PayPal checkout page. If you would like to pay another way, you will be asked to upload a Payment Plan form.
Payment Method* Payment Plan Frequency* If you opt for a payment plan, we will email you a form to fill out with your credit card information.
Remaining Balance Due
Price:
$0.00
Total Due Today
$0.00
Untitled 