2025-2026 Religious School Enrollment - Form

Name of the parent or guardian enrolling children in Religious School

How many children are you enrolling in Religious School for this year?

Name of first child

Grade (1st) child will be in for the 23-24 school year (Secular)

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?

YesNo

Name of second child

Grade (2nd) child will be in for the 23-24 school year (Secular)

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?

YesNo

Name of third child

Grade (3rd) child will be in for the 23-24 school year (Secular)

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?

YesNo

Name of fourth child

Grade (4th) child will be in for the 23-24 school year (Secular)

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)

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 consentNo, I do not give consentI, 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?

YesNo

Minor (child) Photo Release

I consent to my children's photograph on CBS private social media accounts.I consent to my children's photograph on CBS public social media accounts.I consent to my children's photograph on the CBS website.Please do not use my children's photograph for any purpose.

As parent or legal guardian of the child or children whose names have been filled out above, I grant Congregation Bayt Shalom my permission to use the photographs described as synagogue activity images (including community room, library, kitchen, playground, and sanctuary, as well as off-site synagogue events) in which my child/children appear for any legal use, including but not limited to publicity, illustration, advertising, web and social media content.

Furthermore, I understand that no royalty, fee, or other compensation shall become payable to me by reason of such use.

Please choose your preferences above.

Minor Photo Release Signature

By typing your name in the box, this acts as your signature.