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2023-2024 Religious School Enrollment
Please verify reCaptcha before submitting the form.
Name of the parent or guardian enrolling children in Religious School
How many children are you enrolling in Religious School for this year?
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Name of first child
Grade (1st) child will be in for the 23-24 school year (Secular)
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Secular School (1st child)
Student's Hebrew Name
Student's Cell Phone Number
Student's Email
Student's Allegries or Medical Conditions
If you would prefer to discuss medical information confidentially with Rabbi Rose, please contact her.
Are you enrolling another student?
Yes
No
Name of second child
Grade (2nd) child will be in for the 23-24 school year (Secular)
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Secular School (2nd child)
Student's Hebrew Name
Student's Cell Phone Number
Student's Email
Student's Allegries or Medical Conditions
If you would prefer to discuss medical information confidentially with Rabbi Rose, please contact her.
Are you enrolling another student?
Yes
No
Name of third child
Grade (3rd) child will be in for the 23-24 school year (Secular)
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Secular School (3rd child)
Student's Hebrew Name
Student's Cell Phone Number
Student's Email
Student's Allegries or Medical Conditions
If you would prefer to discuss medical information confidentially with Rabbi Rose, please contact her.
Are you enrolling another student?
Yes
No
Name of fourth child
Grade (4th) child will be in for the 23-24 school year (Secular)
0
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Secular School (4th child)
Student's Hebrew Name
Student's Cell Phone Number
Student's Email
Student's Allegries or Medical Conditions
If you would prefer to discuss medical information confidentially with Rabbi Rose, please contact her.
Name
If the school is unable to reach me, you are authorized to release my child(ren) to this person. Enter Name.
Name of fifth child
Grade (5th) child will be in for the 23-24 school year (Secular)
0
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Secular School (5th child)
Student's Hebrew Name
Student's Cell Phone Number
Student's Email
Student's Allegries or Medical Conditions
If you would prefer to discuss medical information confidentially with Rabbi Rose, please contact her.
Authorized Adult's Name
If the school is unable to reach me, you are authorized to release my child(ren) to this person. Enter Name.
Authorized Adult's Relationship to Child(ren)
Relationship to the student
Authorized Adult's Phone Number
Cell phone number of authorized adult.
Emergency Contact
Emergency Contact Name
Relationship
Relationship to the student
Emergency Contact Phone Number
Phone number of emergency contact
Parental Consent to Emergency Care
Yes, I give consent
No, I do not give consent
I, the undersigned parent/guardian of the above child, authorize Congregation Bayt
Shalom Religious School and its authorized representatives as agents for the
undersigned, to consent to an X-ray examination, anesthetic, medical or surgical
diagnosis or treatment and hospital care which is deemed advisable to be rendered
under the general or specific supervision of any licensed physician or dentist (under the
provision of the state’s medicine practice acts) or the staff of a licensed hospital,
whether such diagnosis, examination or treatment is rendered at the office of said
physician, dentist or such hospital.
It is understood that this authorization is given in advance of any specific examination,
diagnosis, treatment, or hospital care being required, and is given to provide authority
and power of our above-named agents to give specific consent to any and all such
examinations, diagnoses, treatments, or hospital care which the aforementioned
physician or dentist in the exercise of his best judgment may deem advisable.
It is also understood that effort shall be made to contact the undersigned prior to
rendering treatment to the patient, but that any of the above treatment will not be
withheld if the undersigned cannot be reached.
Emergency Information: Doctor's Name
Student's doctor's name.
Emergency Information: Doctor's Phone Number
Doctor's phone number
Emergency Information: Dentist's Name
Student's dentist's name.
Emergency Information: Denstist's Phone Number
Dentist's phone number
Emergency Information: Insurance Policy
Insurance Policy Name
Emergency Information: Insurance Policy Number
Insurance Policy Number
Religious School ennrollment and payment was noted on the membership renewal form?
Yes
No
Minor (Child) Photo Release
As parent or legal guardian of the child or children’s names printed below, I grant
Congregation Bayt Shalom my permission to use the photographs described as
synagogue activity images (including community room, library, kitchen, playground, and
sanctuary) in which my child/children appear for any legal use, including but not limited
to publicity, illustration, advertising, and web content.
Furthermore, I understand that no royalty, fee, or other compensation shall become
payable to me by reason of such use.
By typing your name in the above box, this acts as your signature.
Fri, November 8 2024 7 Cheshvan 5785
