1. NAME
Last First Middle Hebrew
2. ADDRESS
Street City State Zip Code
6. RELIGIOUS SCHOOL GRADE (please circle) Pre-K Gan Alef Bet Gimmel Dalet Hay Vav Zayin Midrasha
7. All RS Classes will meet on Sunday mornings. Students in Grades 3-7 must choose Monday or Wednesday as their
second day. Please check one: MONDAY WEDNESDAY
Please number your time preferences from 1 - 3. We will do our best to accommodate your choices; time slots
are limited to 5 students per grade, and preferences will be granted on a first-come, first serve basis.
Time Slot: ___ 4:00-4:40 pm ___ 4:40-5:20 pm ___ 5:20-6:00 pm ___ 6:00-6:40 pm
12. Is there any other information about your child that will help us meet his or her educational needs? If so, please explain:
Placement of children in a particular class is at the discretion of our Religious School Principal.
It is understood and agreed that designees of the principal may photograph, film, videotape, audiotape or reproduce written materials of
the applicant for use in publications and publicity.
It is understood and agreed that student contact information – including phone numbers and addresses – will be given out in the form of a
class list or in response to a classmate’s request to send an invitation for a celebration, such as Bar/Bat Mitzvah.
If and when the need for medical and/or surgical attention arises during the period of my child's official participation in the Judy and
Ronald Mack School of Religious Studies, I hereby grant permission for my child to be transported by private vehicle or ambulance to an
appropriate medical facility and to be treated by qualified medical authorities at their discretion and that of the program leaders.
I am enclosing a non-refundable deposit in the amount of $200 payable to Temple Beth Sholom.
FINAL PAYMENT is due by December 1, 2008.
________________________________
Student’s Name (PRINT)
ALLERGIES TO MEDICATION AND FOOD
Does your child suffer from any allergies? (e.g. bee sting, medications, etc.) Y N
NON-PRESCRIPTION MEDICATIONS
My child has my permission to self-administer the following non-prescription medications:
PRESCRIPTION MEDICATIONS
MEDICAL INSURANCE