Religious School Application For Enrollment

Registration Requirements, Discount and Information
In order to enroll and have your child attend our Religious School, your Beth Israel membership must be in good standing and all financial commitments must remain current throughout the school year. Payments made to Beth Israel are first applied to membership payment plans, then other obligations including Religious School, with the exception of families whose payments are set up using an auto pay system.
The first $100 of the tuition is non-refundable and must accompany this application. Your $100 deposit will hold space in our school for your child(ren). Tuition will be prorated for children enrolled after December 31, 2015.
***Scholarship form may be found at http://cbisd.org/youth/religiousschool/register-school/. Scholarship forms must accompany the registration form below. Scholarships are very limited and will be awarded in the order in which they are received and prioritized based on need.***
Pricing
Transitional K: Varies by number of days $80-$225
Grade K: $850
Grade 1-2: $875
Grade 3: $1,200
Grade 4-6: $1,400 (Includes camp weekend, except transporation fee)
Grade 7: $1,125 (Includes camp weekend, except transporation fee)
Grade 8: $1,100 (Includes weekly dinner)
Grade 9: $1,100 (Includes weekly dinner)
Grade 10: $1,100 (Includes weekly dinner)
Grade 11-12: $825 (Includes weekly dinner)
Required fields*
Please check here to indicate that you understand the above information
Page 1 of 6

Parent/Guardian Information
1st Parent/Guardian Name*
First NameLast Name
Cell Phone*
Area CodePhone Number
Home Phone
Area CodePhone Number
Work Phone
Area CodePhone Number
E-mail*
2nd Parent/Guardian Name
First NameLast Name
Cell Phone
Area CodePhone Number
Home Phone
Area CodePhone Number
Work Phone
Area CodePhone Number
E-mail
Are you new to Beth Israel this year?*
YesNo
Would you like a phone call from a parent involved in the Religious School? *
YesNo
Page 2 of 6

Information for Child 1
Name of Student 1*
First NameMiddle NameLast Name
Grade in September 2015*
Birth Date*
MonthDayYear
Gender:*
If student is 8th-12 grade, please provide their e-mail and cell phone:
Student 1 E-mail
Student 1 Cell Phone Number
Area CodePhone Number
Secular School
Secular School District
Hebrew name (if known)
Previous religious school education (school and dates):
Medical Needs for Child 1
Does your child have any medical/emotional problems of which we should be aware?*
Please explain your child's medical/emotional needs here*
Does your child have any allergies?*
Please describe your child's allergies here*
Is your child on any regular medication?*
Please list your child's regular medications here.*
Does your child receive extra help outside the classroom at his/her secular school? (i.e. IEP, speech therapy, reading resource, etc.)?*
Please explain the type of help he/her receives here.*
Add another child?*
NoYes
Page 3 of 6 (Child 1)

Information for Child 2
Name of Student 2*
First NameMiddle NameLast Name
Grade in September 2015*
Birth Date*
MonthDayYear
Gender:*
If student is 8th-12 grade, please provide their e-mail and cell phone:
Student 2 E-mail
Student 2 Cell Phone Number
Area CodePhone Number
Secular School
Secular School District
Previous religious school education (school and dates):
Hebrew name (if known)
Medical Needs for Child 2
Does your child have any medical/emotional problems of which we should be aware?*
Please explain your child's medical/emotional needs here*
Does your child have any allergies?*
Please describe your child's allergies here*
Is your child on any regular medication?*
Please list your child's regular medications here.*
Does your child receive extra help outside the classroom at his/her secular school? (i.e. IEP, speech therapy, reading resource, etc.)?*
Please explain the type of help he/her receives here.*
Add another child?*
NoYes
Page 3 of 6 (Child 2)

Information for Child 3
Name of Student 3*
First NameMiddle NameLast Name
Grade in September 2015*
Birth Date*
MonthDayYear
Gender:*
If student is 8th-12 grade, please provide their e-mail and cell phone:
Student 3 E-mail
Student 3 Cell Phone Number
Area CodePhone Number
Hebrew name (if known)
Previous religious school education (school and dates):
Secular School
Secular School Dsitrict
Medical Needs for Child 3
Does your child have any medical/emotional problems of which we should be aware?*
Please explain your child's medical/emotional needs here*
Does your child have any allergies?*
Please describe your child's allergies here*
Is your child on any regular medication?*
Please list your child's regular medications here.*
Does your child receive extra help outside the classroom at his/her secular school? (i.e. IEP, speech therapy, reading resource, etc.)?*
Please explain the type of help he/her receives here.*
Add another child?*
NoYes
Page 3 of 6 (Child 3)

Information for Child 4
Name of Student 4*
First NameMiddle NameLast Name
Grade in September 2015*
Birth Date*
MonthDayYear
Gender:*
If student is 8th-12 grade, please provide their e-mail and cell phone:
Student 4 E-mail
Student 4 Cell Phone Number
Area CodePhone Number
Hebrew name (if known)
Previous religious school education (school and dates):
Secular School
Secular School District
Medical Needs for Child 4
Does your child have any medical/emotional problems of which we should be aware?*
Please explain your child's medical/emotional needs here*
Does your child have any allergies?*
Please describe your child's allergies here*
Is your child on any regular medication?*
Please list your child's regular medications here.*
Does your child receive extra help outside the classroom at his/her secular school? (i.e. IEP, speech therapy, reading resource, etc.)?*
Please explain the type of help he/her receives here.*
If you wish to enroll more than 4 students in Religious School, please complete this application for the first four and complete an additional application as necessary.
Page 3 of 6 (Child 4)

Family Background
We respectfully ask that you complete this section in order that we may be more sensitive to the needs of your child. This information will be kept in confidence and only shared with teachers.
Are both parents Jewish?
If "no", which parent/guardian is not and what religion is practiced?
Is a religion other than Judaism practiced in your home?
If "yes", please explain.
Are there any stepparents in your child's family?
If "yes", please name them.
Page 4 of 6

Tuition and Additional Fees
Beth Israel will not refund any tuition fees paid or cancel any unpaid obligations when a child is absent or withdrawn during the year. Once you submit this Religious School Registration Form, you are legally obligated for the FULL tuition amount.
Periodically there may be additional fees for optional items such as field trips, special events, camp weekend transportation, and other miscellaneous items. These will be billed separately, if used, and are not included in tuition fees.
EMERGENCY & MEDICAL INFORMATION
Occasionally an emergency arises when it is necessary for a School representative to contact parents when their children are at school. Every effort will be made to notify the parents or someone designated by them if a child should become very ill or be involved in an accident. If this cannot be done, the policy of the Temple is to transport the child to the nearest emergency hospital. This action will be taken in all such cases unless instructions to the contrary are provided by the parents.

(We), the undersigned, parents/guardian of a minor(s), do hereby authorize the Religious School as agent for the undersigned to consent to any x-ray examination, anesthetic, medical or surgical diagnosis or treatment, and hospital care which is to be rendered under the general or special supervision of any physician or surgeon licensed under the provisions of the California Medicine Practice Act on the medical staff of a hospital, whether such examination, diagnosis or treatment is rendered at the office of said physician or at such a 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 on the part of our above-named agent to give specific consent to any and all such examinations, diagnoses, treatment or hospital care which the aforementioned physician in the exercise of his/her judgment may deem advisable.
This authorization is given pursuant to the provisions of Section 25.8 of the Civil Code of California and will cover attendance at all authorized functions.
Name of Neighbor/Friend*
Phone Number of Neighbor/Friend*
Name of Relative*
Phone Number of Relative*
Doctor/Medical Group Name*
Phone Number of Doctor/Medical Group *
Insurance Company Name*
Phone Number of Insurance Company*
Please check "Yes" or "No" to provide your consent.*
YesNo
PERMISSION SLIP
I hereby grant permission for my child/children to participate in Beth Israel's Religious School activities and events and to release Beth Israel and its representatives from all liability arising out of my child's participation.
Please check "Yes" or "No" to provide your consent.
Required field*
YesNo
MEDIA ACKNOWLEDGMENT
I further grant permission for Congregation Beth Israel to use my child’s image and voice in printed & electronic materials, with the knowledge that no last names will be used on a public document.
Please check "Yes" or "No" to provide your consent.
Required field*
YesNo
Authorize your consent by typing the name of one parent or guardian here:*
Click to edit
Should be Empty:

Transitional K Grades K-2	Sundays, 9:00-11:30 a.m. Sundays, 9:00-11:30 a.m.
Grades 3-6	Sundays, 9:00-11:30 a.m. and Wednesdays, 4:00-6:00 p.m. OR Sundays, 9:00-11:30 a.m. and Thursdays, 4:00-6:00 p.m. *The mid-week class days CANNOT be changed after August 20, 2015 or anytime throughout the school year*
Grade 7	Tuesdays, 4:00-5:50 p.m.
Grades 8-12	Tuesdays, 5:50-8:00 p.m.

Registration Requirements, Discount and Information

Pricing

Parent/Guardian Information

Information for Child 1

Medical Needs for Child 1

Information for Child 2

Medical Needs for Child 2

Information for Child 3

Medical Needs for Child 3

Information for Child 4

Medical Needs for Child 4

Family Background

Grade selection and Payment Details

Payment Details

Payment Options

Credit Card Offset Donation

YOU CAN HELP OTHERS

ADDITIONAL COMMENTS/CLASS PLACEMENT REQUESTS

Tuition and Additional Fees

EMERGENCY & MEDICAL INFORMATION

PERMISSION SLIP

MEDIA ACKNOWLEDGMENT