2024-2025 Religious School Registration - Form

* Is your family new to our school?

Please Select OneNoYes

Section A: Family Contact Information

* First Name (Primary)

* Last Name (Primary)

* Email (Primary)

* Phone (Primary)

* Relationship to Student(s) (Primary)

* Street Address (Primary)

Street Address Line 2 (Primary)

* City (Primary)

* State (Primary)

* ZIP (Primary)

* Is there a secondary contact?

Please Select OneNoYes, at the same address as the primary contactYes, but at a different address than the primary contactIf there is a secondary contact, all emails and mailings will go to both contacts. In case of urgent need, the primary contact will be notified first

* First Name (Secondary)

* Last Name (Secondary)

* Email (Secondary)

* Phone (Secondary)

* Relationship to Student(s) (Secondary)

* Street Address (Secondary)

Street Address Line 2 (Secondary)

* City (Secondary)

* State (Secondary)

* ZIP (Secondary)

Should my child(ren) become ill and a parent/guardian cannot be reached, please notify one of the following people to pick up my child(ren). If there should be a civil or defense emergency or natural disaster, the following people are authorized to pick up my child(ren).

* Emergency Contact Name

* Emergency Contact Phone

* Emergency Contact Relationship

* Emergency Contact Name

* Emergency Contact Phone

* Emergency Contact Relationship

Section B: Student Enrollment Information

Student 1 Information

* Student 1 First Name

* Student 1 Last Name

* Student 1 Birthdate

* Student 1 Hebrew Name

Student 1 Nickname (if applicable)

* Student 1 Grade in Religious School

* REQUIRED $75 Security Fee Per Family

REQUIRED $75 Security Fee Per Family

* Student 1 Secular School Name

Student 1 Email (if applicable)
Information will not be shared publicly. Parents will be copied on all communication to students.

Student 1 Phone (if applicable)
Information will not be shared publicly. Students will not be contacted independently from parents.

* Student 1 Special Learning Needs
Please Select OneNoYes (IEP or 504)If yes, please send to dhubara@emanu-el.com a copy or a letter specifying the accommodations that we need to make in order to serve this student effectively. Please detail any physical, emotional or learning needs.

* Does your child have allergies or medications we need to know about?
Please Select OneNoYesStudent 1 Allergies or Medications

Student 1 Allergy/Medication Details
Please describe allergies and medications with dosage and timing.

Student 2 Information

* Student 2 First Name

* Student 2 Last Name

* Student 2 Birthdate

* Student 2 Hebrew Name

Student 2 Nickname (if applicable)

* Student 2 Grade in Religious School

$25 Sibling Discount (After the First Child)

* Student 2 Secular School Name

Student 2 Email (if applicable)
Information will not be shared publicly. Parents will be copied on all communication to students.

Student 2 Phone (if applicable)
Information will not be shared publicly. Students will not be contacted independently from parents.

* Student 2 Special Learning Needs
Please Select OneNoYes (IEP or 504)If yes, please send to dhubara@emanu-el.com a copy or a letter specifying the accommodations that we need to make in order to serve this student effectively. Please detail any physical, emotional or learning needs.

* Does your child have allergies or medications we need to know about?
Please Select OneNoYesStudent 2 Allergies or Medications

Student 2 Allergy/Medication Details
Please describe allergies and medications with dosage and timing.

Student 3 Information

* Student 3 First Name

* Student 3 Last Name

* Student 3 Birthdate

* Student 3 Hebrew Name

Student 3 Nickname (if applicable)

* Student 3 Grade in Religious School

* Student 3 Secular School Name

Student 3 Email (if applicable)
Information will not be shared publicly. Parents will be copied on all communication to students.

Student 3 Phone (if applicable)
Information will not be shared publicly. Students will not be contacted independently from parents.

* Student 3 Special Learning Needs
Please Select OneNoYes (IEP or 504)If yes, please send to dhubara@emanu-el.com a copy or a letter specifying the accommodations that we need to make in order to serve this student effectively. Please detail any physical, emotional or learning needs.

* Does your child have allergies or medications we need to know about?
Please Select OneNoYesStudent 3 Allergies or Medications

Student 3 Allergy/Medication Details
Please describe allergies and medications with dosage and timing.

Student 4 Information

* Student 4 First Name

* Student 4 Last Name

* Student 4 Birthdate

* Student 4 Hebrew Name

Student 4 Nickname (if applicable)

* Student 4 Grade in Religious School

* Student 4 Secular School Name

Student 4 Email (if applicable)
Information will not be shared publicly. Parents will be copied on all communication to students.

Student 4 Phone (if applicable)
Information will not be shared publicly. Students will not be contacted independently from parents.

* Does your child have allergies or medications we need to know about?
Please Select OneNoYesStudent 4 Allergies or Medications

* Student 4 Special Learning Needs
Please Select OneNoYes (IEP or 504)If yes, please send to dhubara@emanu-el.com a copy or a letter specifying the accommodations that we need to make in order to serve this student effectively. Please detail any physical, emotional or learning needs.

Student 4 Allergy/Medication Details
Please describe allergies and medications with dosage and timing.

Section C: Release Forms

Medical Release

In the event of a medical emergency involving my child, I hereby authorize Synagogue Emanu-El to take necessary measure to have my child treated. It is understood that this will be done only after all reasonable efforts have been made to contact my physician and parent/legal guardian. Neither I, nor any other representative of our family will sue, claim against, attack the property of, or prosecute Synagogue Emanu-El, it's directors, agents, employees, and all affiliated entities for loss of property, injury, harm, accident, illness, loss of limb or life, or other personal injury, incapacity, medical cost ,expense, damage, claim, or liability howsoever caused, and regardless of whether caused directly or indirectly, by my child's acts or any acts arising out of or in connection with their participation in Synagogue Emanu-El.

I certify that my child(ren) is(are) in good physical health. They have my permission to participate in all activities that are part of the regular religious school program.

My child(ren) may take
TylenolAdvil

My child(ren) may NOT take
TylenolAdvil

* Medical Release: Enter your name below
By typing my name, I confirm I have read, understand and agree to the above.

Media Release

From time to time your child’s photo may be taken in our classrooms or special events. We use these photos in the synagogue newsletters, on our synagogue website as well as our Facebook groups and other publicity materials.

* Media Release
Please Select OneI grant permission for my child's image to be usedI do not grant permission for my child’s image to be used

I give permission for my family's name, address, telephone and e-mail address to be included in a school directory.
YesNo

Consent, Authorization, and Release

The Minor has my consent to attend and participate in Religious School and Youth scheduled activities. There are no limitations or restrictions of any kind whatsoever on such participation unless this box is checked with an explanation.
The Minor has my consent to attend and participate in Religious School and Youth scheduled activities. There are no limitations or restrictions of any kind whatsoever on such participation unless this box is checked with an explanation.

You are expressly authorized to administer, prescribe and/or direct the administration of any medication, other medical treatment, care, surgery, hospitalization or medical procedures and services deemed appropriate under the circumstances, if you are not able to timely contact me for instructions, acting as my authorized agent and at my sole cost and expense. There are no exceptions or limitations or other special instructions in connection with foregoing, unless this box is checked with an explanation.
You are expressly authorized to administer, prescribe and/or direct the administration of any medication, other medical treatment, care, surgery, hospitalization or medical procedures and services deemed appropriate under the circumstances, if you are not able to timely contact me for instructions, acting as my authorized agent and at my sole cost and expense. There are no exceptions or limitations or other special instructions in connection with foregoing, unless this box is checked with an explanation.

Unless this box is checked and I have provided you with specific instructions, directions or other specific data to the contrary, in the box. You assume that the minor has no medical disabilities, allergies or other limitations of any kind whatsoever that might in any way limit participation in scheduled activity.
Unless this box is checked and I have provided you with specific instructions, directions or other specific data to the contrary, in the box. You assume that the minor has no medical disabilities, allergies or other limitations of any kind whatsoever that might in any way limit participation in scheduled activity.

The Minor has been instructed by me, and understands and agrees to comply with all rules, regulation and Codes of Conduct established by Synagogue Emanu-El and the official instructions and directives of all authorized staff members, volunteers, agents, and employees ("Personnel") of Synagogue Emanu-El.
The Minor has been instructed by me, and understands and agrees to comply with all rules, regulation and Codes of Conduct established by Synagogue Emanu-El and the official instructions and directives of all authorized staff members, volunteers, agents, and employees ("Personnel") of Synagogue Emanu-El.

I expressly release and agree to indemnify and hold Synagogue Emanu-El and it's personnel free and harmless from any and all liability, charges, claims, costs, and expenses of every kind and nature whatsoever, including reasonable attorney fees, in connection with the acceptance and participation of the minor in scheduled activity. The forgoing release is without reservation of any kind expect only for such acts or omissions on your part that arise out of your intentional or negligent wrongdoing and without fault of any kind on the part of the minor or on my part in failing to disclose pertinent information to you.
I expressly release and agree to indemnify and hold Synagogue Emanu-El and it's personnel free and harmless from any and all liability, charges, claims, costs, and expenses of every kind and nature whatsoever, including reasonable attorney fees, in connection with the acceptance and participation of the minor in scheduled activity. The forgoing release is without reservation of any kind expect only for such acts or omissions on your part that arise out of your intentional or negligent wrongdoing and without fault of any kind on the part of the minor or on my part in failing to disclose pertinent information to you.

I represent to you that I have the sole, full and legal power and right to execute this consent and that you will rely on my representations.
I represent to you that I have the sole, full and legal power and right to execute this consent and that you will rely on my representations.

If this consent is signed by more that one person, all references to the singular shall include the plural, jointly and severally.

I DECLARE UNDER THE PENALTY OF PERJURY THAT I HAVE READ AND FULLY UNDERSTAND THE IMPORTANCE AND THE EFFECT OF THE FOREGOING CONSENT, AUTHORIZATION, AND RELEASE: THAT I HAVE OBTAINED SUCH ADVICE OF AN ATTORNEY AND OF A LICENSED PHYSICIAN AS I DEEMED NECESSARY, TO MY COMPLETE SATISFACTION; AND THAT I SIGNED THIS CONSENT ON

Student(s) Name(s):

First & Last Name of Adult 1

First & Last Name of Adult 2

Relationship to Minor(s)

Insurance Company Name

Policy Number

Insurance Address & Phone

Section D: Congregation Community

You may have noticed that at the top of the form we begin with family information. This is intentional. The work of raising and educating Jewish children cannot be done in the school alone, but is a project of the school, the family and the community. You are not just registering your child(ren) for school today, but in fact your entire family. When you come in the building and spend time learning and volunteering with us, you make a powerful statement to your children that Jewish learning is a lifelong process and that we are all on the same team in creating these experiences for them. Don’t underestimate the subtle power of this statement!

In addition to those opportunities to participate we are in need of regular volunteers to make our school work. Would you consider supporting our school in an ongoing role or a limited engagement?

Ongoing Opportunities (check all that apply)
Kitchen Activity HelperSubstitute TeachingChesed Project Planning

Limited Engagements (check all that apply)
Party ChaperoneCooking Demonstration Prep

Any other skills or talents you might be willing to share?

Section E: Payment Information

* Do you require financial aid?
Please Select OneNoYesIf you select yes, you will discuss your payment ability privately.
Please contact Daphne at dhubara@emanu-el.com.

Financial Aid Follow-up: I understand and will contact Daphne Hubara
Financial Aid Follow-up: I understand and will contact Daphne Hubara

Total Amount