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TEMPLE SHALOM RELIGIOUS SCHOOL ON-LINE ENROLLMENT FORM
Please include area codes with ALL phone numbers; enter dates as mm/dd/yyyy. *REQUIRED
Your Name*:
Your E-Mail*:
Father/Parent/Guardian Mother/Parent/Guardian
Last Name:
First Name:
Street:
City:
State:
Zip:
Home Phone (w/area):
Cell Phone (w/area):
Work Phone (w/area):
Personal E-Mail:
Child Resides with:
How would you like to receive communications?
Parent not living with children who
should receive school mailings if applicable
Last Name:
First Name:
Street:
City:
State:
Zip:
E-Mail:
List all children enrolling in current
Religious School (K-12th)
1. Student's Full Name:
1. Age:
1. Birth Date:
1. Day School :
1. Grade:
1. Hebrew Name:
2. Student's Full Name:
2. Age:
2. Birth Date:
2. Day School:
2. Grade:
2. Hebrew Name:
3. Full Name:
3. Age:
3. Birth Date:
3. Day School:
3. Grade:
3. Hebrew Name:
4. Student's Full Name:
4. Age:
4. Birth Date:
4. Day School:
4. Grade:
4. Hebrew Name:
Please list children NOT currently enrolled
in Religious School if applicable
1. Name:
1. Age:
1. Grade:
2. Name:
2. Age:
2. Grade:
3. Name:
3. Age:
3. Grade:
Please list 2 people to whom student may be
released in case of an emergency
1. Name:
1. Relationship:
1. Phone (w/area):
2. Name:
2. Relationship:
2. Phone (w/area):
MEDICAL RELEASE
Doctor's Name:
Doctor's Phone:
Allergies or special medical conditions:
May we administer Tylenol to your child?
I/we hereby give permission for the enrolled child(ren) to be given emergency care as administered, authorized or directed by any adult person acting on behalf of Temple Shalom Religious School. Such care may include x-ray examination, rendered to said minor under the provisions of the Medicine Practice Act; anesthetic, dental or surgical diagnosis or treatment or hospital care to be rendered to said minor by a dentist licensed under the provisions of the Dental Practice Act, all pursuant to Civil Code 25.8. I/we further agree to pay the cost of all such medical or dental services. It is understood that if time and circumstances reasonably permit, Temple Shalom Religious School personnel will try, but not be required, to communicate with me prior to such treatment.
PERSONAL STUDENT INFORMATION
1. Student Name:
1. Student Cell Phone (w/area):
2. Student Name:
2. Student Cell Phone (w/area):
3. Student Name:
3. Student Cell Phone (w/area):
Please describe any special needs that might affect your
child's performance or participation in class if applicable
Student 1:
Student 2:
Student 3:
If you wish, please share your expectations regarding your
child's Jewish education at Temple Shalom Religious School
Student 1:
Student 2:
Student 3:
PERMISSION RELEASE
I/We hereby give permission for our son/daughter to attend all scheduled activities either on or off school premises. I/We give permission for our son/daughter to travel by private car, contracted vehicle or by foot to the school sponsored event(s). I/We understand that Temple Shalom will provide adequate supervision for all events and that Temple Shalom will make every reasonable effort to ensure the safety of all participants. However, I/We are aware that as a non-profit organization, Temple Shalom cannot, and will not assume responsibility for any accidents or loss of per onal effects at any activity/event. I/We hereby release Temple Shalom from any liability whatsoever which may arise as a result of transportation to and/or from events, for any injury to my/our child during events, anaive any claim that hereafter may arise, specifically not to sue or bring action against Temple Shalom or its representatives.