Religious School Registration Form 2016-2017

The Religious School of B'nai Tikvah
K-12th Grade Registration

Please submit information no later than July 31,2016. If you need a paper form, please contact Sue Brin: sbrin@bnaitikvah.net

Please note the extensive nature of our form. All fields are required unless otherwise indicated.
Student Information
Student Name 1

First NameLast Name
Birth Date

MonthDayYear
Male or Female?

MaleFemale
Hebrew Name (transliterated)
Secular School Grade 2016-2017
Secular School
Friend Request 1 (optional)
Friend Request 2 (optional)
Student Name 2

First NameLast Name
Birth Date

MonthDayYear
Male or Female?

MaleFemale
Hebrew Name (transliterated)
Secular School Grade 2016-2017
Secular School
Friend Request 1 (optional)
Friend Request 2 (optional)
Student Name 3

First NameLast Name
Birth Date

MonthDayYear
Male or Female?

MaleFemale
Hebrew Name (transliterated)
Secular School Grade 2016-2017
Secular School
Friend Request 1 (optional)
Friend Request 2 (optional)
Parent/Guardian Information
Parent/Guardian 1

First NameLast Name
Address 1

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
E-mail 1
Home Phone 1

Area CodePhone Number
Work Phone 1

Area CodePhone Number
Cell Phone 1

Area CodePhone Number
Parent/Guardian 2

First NameLast Name
Address 2

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
E-mail 2
Home Phone 2

Area CodePhone Number
Work Phone 2

Area CodePhone Number
Cell Phone 2

Area CodePhone Number
Child residing with
Emergency Information
Physician's Name
Phone Number

Area CodePhone Number
Insurance Carrier
Policy #
If Parent or Guardian cannot be contacted:

First NameLast Name
Relationship
Home Phone

Area CodePhone Number
Cell Phone

Area CodePhone Number
Work Phone

Area CodePhone Number
Emergency Medical Treatment
In case of emergency, we hereby authorize (by our indication below) the Director of Lifelong Learning, Administrator, or Teacher to call our physician or take our child/ren to the hospital to receive appropriate emergency treatment.*

We AuthorizeWe DO NOT Authorize
Field Trip
I hereby authorize my child/ren to participate in field trips and programs with his/her class. I agree to hold our congregation (including its board, officers, staff and volunteers) harmless from any and all claims that may arise out of his/her participation in school trips and programs. Note: Parents will receive advance notice about field trips held throughout the year.*

We AuthorizeWe DO NOT Authorize
Photograph/Video Release
I hereby give permission to use the name and likeness, including photographs/videos of the minor(s) named above, for publicity, promotion, news release, videos and web use of our congregation and our school. This permission might also apply to written compositions or visual art created by the minor if selected for such use.*

We give permissionWe DO NOT give permission
We can serve your child best if we know about your child

(All information you share will be kept strictly confidential)
Does your child/ren have any medical concerns (allergies, medications, etc.)? Please be specific.
Does your child/ren have any learning issues that we should be aware of (ADD, ADHD, speech and language, dyslexia, developmental delays, etc.)?
Is there anything else you think we should know about your child/ren (temperament, strengths, friends, etc.)?
Does your child/ren have an IEP (Individual Education Plan) or 504 plan at his/her secular school?

YesNo
Volunteering
Would you like to be contacted about volunteer opportunities?

YesNo
Primary Contact
Once you have completed this form, please click on the submit button below. Please expect to be contacted by our bookkeeper about school tuition payment. Todah Rabbah!
Should be Empty:

The Religious School of B'nai Tikvah

Student Information

Parent/Guardian Information

Emergency Information

Emergency Medical Treatment

Field Trip

Photograph/Video Release

We can serve your child best if we know about your child

Volunteering

Once you have completed this form, please click on the submit button below. Please expect to be contacted by our bookkeeper about school tuition payment. Todah Rabbah!