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Temple Shalom Religious School Registration 21-22
Please verify reCaptcha before submitting the form.
Please note: You will be asked for your child(ren)'s Medical Insurance Information. It may be helpful to have it handy.
Student Information
How many children will you be enrolling?
Please Select One
1
2
3
4
*
Last Name_Child 1
*
First Name_Child 1
Nickname (if any)_Child 1
*
Birth Date_Child 1
*
Age_Child 1
*
Gender_Child 1
Please Select One
Male
Female
Other
Ethnicity_Child 1
Please Select One
African American
Asian
Caucasian
Hawaiian/Pacific Islander
Hispanic/Latino
Middle Eastern
Other
Prefer not to answer
*
Public/Private School Name_Child 1
Most recently attended
*
Grade_Child 1
Most recently enrolled
Please list all allergies, medications or medical conditions (Child_1):
Does your child have special learning needs (Child_1)?
If yes, please explain.
*
Last Name_Child 2
*
First Name_Child 2
Nickname (if any)_Child 2
*
Birth Date_Child 2
*
Age_Child 2
*
Gender_Child 2
Please Select One
Male
Female
Other
Ethnicity_Child 2
Please Select One
African American
Asian
Caucasian
Hawaiian/Pacific Islander
Hispanic/Latino
Middle Eastern
Other
Prefer not to answer
*
Public/Private School Name_Child 2
Most recently attended
*
Grade_Child 2
Most recently enrolled
Please list all allergies, medicines and medical condition (Child_2)
Does your child have special learning needs? (Child_2)
If so, please explain
*
Last Name_Child 3
*
First Name_Child 3
Nickname (if any)_Child 3
*
Birth Date_Child 3
*
Age_Child 3
*
Gender_Child 3
Please Select One
Male
Female
Other
Ethnicity_Child 3
Please Select One
African American
Asian
Caucasian
Hawaiian/Pacific Islander
Hispanic/Latino
Middle Eastern
Other
Prefer not to answer
*
Public/Private School Name_Child 3
Most recently attended
*
Grade_Child 3
Most recently enrolled
Please list all allergies, medicines and medical condition (Child_3)
Does your child have special learning needs? (Child_3)
If so, please explain
*
Last Name_Child 4
*
First Name_Child 4
Nickname (if any)_Child 4
*
Birth Date_Child 4
*
Age_Child 4
*
Gender_Child 4
Please Select One
Male
Female
Other
Ethnicity_Child 4
Please Select One
African American
Asian
Caucasian
Hawaiian/Pacific Islander
Hispanic/Latino
Middle Eastern
Other
Prefer not to answer
*
Public/Private School Name_Child 4
Most recently attended
*
Grade_Child 4
Most recently enrolled
Please list all allergies, medications or medical conditions (Child_4):
Does your child have special learning needs (Child_4)?
If yes, please explain.
Do you have other children NOT enrolled in TS Religious School?
Please Select One
Yes
No
Please indicate the names, ages and religion of other children in your family who are not currently enrolled in the Religious School.
Child(ren)'s Current Residence Information
*
Street Address
*
City
*
State
--Select State--
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
*
Zip
Parent/Guardian Information
*
Last Name
*
First Name
Marital Status
Please Select One
Married
Single
Separated
Divorced
*
Religion
Please Select One
Jewish
Catholic
Protestant
Muslim
Buddhist
Other
*
Home Phone
*
Mobile Phone
*
Email
*
Street Address
(if different from above)
*
City
*
State
*
Zip
*
Would you be interested in being a Class Parent and/or volunteer?
Please Select One
Yes
No
*
Is there another Parent/Guardian?
Please Select One
Yes
No
Second Parent/Guardian Information
*
Last Name
*
First Name
*
Marital Status
Please Select One
Married
Single
Separated
Divorced
*
Religion
Please Select One
Jewish
Catholic
Protestant
Muslim
Buddhist
Other
*
Home Phone
*
Mobile Phone
*
Email
Emergency Contact Information
(Other than Parent/Guardian listed above)
*
Last Name
*
First Name
*
Relationship to child
*
Phone Number
Last Name
First Name
Relationship to child
Phone Number
Medical Information
*
Child's Physician
Name, Address, Phone Number
Child's Dentist
Name, Address, Phone Number
In the event it becomes necessary to bring your child to a hospital for diagnosis or emergency treatment, the Temple Shalom Religious School has my full permission to do so. In the event I am not able to be reached, I give my permission to any medical attendant in charge to provide all necessary emergency treatment should the need arise.
I, as parent/guardian, will assume full responsibility for such arrangements including payment of expenses incurred thereby and shall indemnify and hold harmless Temple Shalom and the Temple Shalom Religious School, teachers, professionals, employees, and staff as well as adult leaders and volunteer parents from any and all liability with respect thereto.
*
Insurance Company Name
*
Name of Medical Policy Holder
*
Medical Policy Number
*
Parent/Guardian Signature
Family Media
Release Policy
During the course of the school year, many of our activities are photographed and video recorded for internal use on our website and social media accounts. We never use names or include personal information that would identify any of our students (The sole exception being the use of first names used with permission for the Rabbi's "B'nai Mitzvah Selfies). On some occasions, news media (print, television, etc.) may wish to film or photograph a school event and may request such information. We will only allow this with written consent from parents, which we will seek prior to the event.
*
I have read and understand to the Family Media Release Policy.
I have read and understand to the Family Media Release Policy.
Fri, April 26 2024 18 Nisan 5784
