Temple Beth Torah Religious School Student Registration

PARENT/GUARDIAN INFORMATION

Name

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Cell Phone

Home Phone

Work Phone

Email

If divorced, custodial parent or guardian:

Besides Parent/Guardian, authorized to drop-off/pick-up:

Anyone who cannot exercise custody:

STUDENT INFORMATION

Last Name

First Name

Nickname

Hebrew Name

Date of Birth

Age

School

Grade

Gender

Has your child been consecrated?

Yes
No

First year in Religious School?

Yes
No

Previous Religious School

Years in Jewish Studies:

Years in Hebrew Studies:

Please let us know if there is any information the Religious School should have to meet your needs.

Special Learning Situations:

MEDICAL INFORMATION:

Medical Conditions:

Allergies:

Medication & Dosage Instructions:

INSURANCE INFORMATION:

Please provide insurance information in case emergency medical service is required

Name of Policy

Policy Number

Policy Name Holder

Preferred Hospital, if possible

EMERGENCY CONTACTS:

Please provide TWO emergency contacts in case we cannot reach a parent/guardian.

Emergency Contact 1 – Name

First

Last

Emergency Contact 1 – Relationship

Emergency Contact 1 – Cell

Emergency Contact 2 – Name

First

Last

Emergency Contact 2 – Relationship

Emergency Contact 2 – Cell

1 Studies: B'Nai

RELIGIOUS SCHOOL TUITION:
Please select grade level for each child enrolling. Tuition rates are per child, per year.

Add B'Nai Mitzvah Fee (Paid in Sixth Grade)

Yes – $1,500.00

PAYMENT DETAILS

Payment Type

Credit Card
Personal Check

PARENT/GUARDIAN INFORMATION

STUDENT INFORMATION

PAYMENT DETAILS

PAY BY CHECK