Masa B'Yachad 2020 Registration Form

Registration Form

2020-2021 School Year
Parent/Guardian 1 Name *

First Name Last Name
Parent/Guardian 1 E-mail *
Home Phone *

Area Code Phone Number
Parent/Guardian 1 Cell Phone

Area Code Phone Number
Parent/Guardian 1 Work Phone

Area Code Phone Number
Parent/Guardian 2 Name

First Name Last Name
Parent/Guardian 2 Email
example@example.com
Parent/Guardian 2 Home Phone (if different)

Area Code Phone Number
Parent/Guardian 2 Cell Phone

Area Code Phone Number
Parent/Guardian 2 Work Phone

Area Code Phone Number
Home Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Parent/Guardian 2 Address (if different)

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Affiliated Congregation *

Congregation Beth Israel Temple Beth-El
Name(s) of Students' Secular School(s) *

Student Information *

	Full Name	Please call me...	Hebrew Name	Birthdate	Grade
Student 1
Student 2
Student 3
Student 4

Any medical issues, medications, or allergies?
Are there any factors affecting your child(ren)'s learning that the school should be aware of?
e.g., vision or hearing impairment, learning accommodations, changes in family status including recent illness or loss, non-Jewish family members, other siblings, etc. You may also contact the principal to discuss these matters or address them in a separate letter.
Religious School Fees
Tuition Rate

CBI/TBE Member Tuition: Sunday School Only (Grades PK-2 and 8-10): $300; Hebrew School + Sunday School (Grades 3-7): $600 Non-Member Tuition: Sunday School Only (Grades PK-2 and 8-10): $500; Hebrew School + Sunday School (Grades 3-7): $800
# Students in Sunday School Only (Gr. PK-2 or Gr. 8-10)
# Students in Hebrew School + Sunday School (Gr. 3-7)
Total Religious School Fees: $
The above amount is payable through your member congregation. If you are in need of financial aid or other special consideration, please contact your congregation. If you do not belong to any congregation, please contact the Jewish Federation of Northwest Indiana at (219) 301-0960 regarding payment arrangements.
Permission/Release Forms
Photography Release Form

I authorize Masa B'Yachad to publish still photographs, video, or both, taken of me or any minor child/ren of mine. I hereby release Masa B'Yachad, its employees, and any third parties involved in the creation or dissemination of its publications, from liability for any claims by me or any third party in connection with my or my child/ren's participation.
Directory Release Form

I authorize Masa B'Yachad to publish my family's contact information in a directory, for distribution to school families only.
Field Trip Release Form *

I give my child/ren permission to attend activities and go on educational field trips sponsored by Masa B' Yachad. I understand that all travel will be by bus or private cars and accompanied by adults. All drivers will have provided evidence of insurance. I release Masa B' Yachad from all responsibility during said field trips. In case of behavior deemed unacceptable to the adult leaders, parent(s)/guardian(s) will be contacted and participation in future field trips will be on a contract basis.
Medical Release Form *

I authorize chaperones and personnel of Masa B'Yachad to give first aid if injury or illness is mild. I authorize chaperones and personnel of Masa B'Yachad to seek and obtain medical treatment for my child/ren in the event of an emergency. I agree to be responsible for any charges incurred concerning such care and treatment that are not covered by my health insurance provider.
Name of Physician
Physician's Contact Phone

Area Code Phone Number
Preferred Clinic/Hospital
Health Insurance Provider
Policy #
In case of a child's injury or illness while involved in classes and activities at Masa B'Yachad Religious School, every effort will be made to contact parent(s)/guardian(s). When injury or illness is serious and parent(s)/guardian(s) cannot be reached, please notify:
Emergency Contact - Name *

First Name Last Name
Emergency Contact - Relationship *
Emergency Contact - Phone *

Area Code Phone Number
Parent Signature

Clear
Additional Comments
Should be Empty:

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Registration Form

Religious School Fees

Permission/Release Forms