Temple Beth Torah Religious School Student Registration

STUDENT INFORMATION

Last Name

First Name

Hebrew Name

Nickname

Date of Birth

Age

School

Grade

Gender

Emergency Name Hebrew

PARENT/GUARDIAN INFORMATION

Parent/Guardian

Parent/Guardian 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:

RELIGIOUS SCHOOL BACKGROUND

First year in Religious School?

Yes
No

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

Special Learning Situations:

EMERGENCY INFORMATION

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

Emergency Contact 1

First Name

Relationship

Last Name

Cell

Emergency Contact 2

First Name

Relationship

Last Name

Cell

MEDICAL INFORMATION

ALLERGIES:

MEDICAL CONDITIONS:

Emergency Medication + Dosing Instructions

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

RELIGIOUS SCHOOL TUITION

Per Child, Per Year

Total

Item Quantity Qty Total

There are no products selected.

Torah Tots – Member 1 $360.00

Torah Tots – Non-Member 1 $480.00

Kindergarten 1 $900.00

First Grade 1 $900.00

Second Grade 1 $900.00

Third Grade 1 $900.00

Fourth Grade 1 $1,275.00

Fifth Grade 1 $1,275.00

Sixth Grade 1 $1,275.00

Seventh Grade 1 $1,275.00

Eighth Grade 1 $700.00

Ninth Grade 1 $700.00

Tenth Grade 1 $700.00

Eleventh Grade 1 $700.00

Twelfth Grade 1 $700.00

Add B’Nai Mitzvah Fee (Paid in Sixth Grade) – Yes 1 $1,500.00

Total $0.00

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