Registration Form
2022-2023
Student Name
*
First Name
Last Name
Student Email
*
example@example.com
Teen Phone Number
*
-
Area Code
Phone Number
Birthdate
*
MM/DD/YYYY
School
*
Grade as of fall 2022
*
8th Grade
9th Grade
10th Grade
11th Grade
12th Grade
T-Shirt Size
*
Small
Medium
Large
X-Large
Synagogue Affiliation
*
Yes
No
If yes, with which synagogue is your family affiliated
Allergies - food, environment, medical, etc.
*
Current medications taking:
*
Dietary needs:
Please indicate gluten free, dairy free, etc.
Contact Information
Parent/Guardian Name
*
First Name
Last Name
Parent/Guardian Phone Number
*
-
Area Code
Phone Number
Parent/Guardian Email
*
example@example.com
Parent/Guardian Name
First Name
Last Name
Parent/Guardian Phone Number
-
Area Code
Phone Number
Parent/Guardian Email
example@example.com
Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Payment Information
Tuition $995 per year. Please make checks payable to Congregation Beth Israel. In the memo line, write "Kehillah High". Mail to Congregation Beth Israel c/o Kehillah High 5600 N. Braeswood Blvd. Houston, TX 77096. If you'd like to pay by credit card or set up a payment plan, please call Stephanie Shargal Robertson at 713-271-7369.
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Health History
2022-2023
Does your child have any special learning needs or learn best in any specific types of educational settings?
*
Yes
No
If yes, please describe
Does your child have any special behavioral or emotional issues we can help support?
*
Yes
No
If yes, please describe
Does your child have an IEP?
*
Yes
No
If yes, please describe
Does your child have any other special issues or needs?
*
Yes
No
If yes, please describe
Health History
Allergies - food, environment, medical, etc.
*
Anaphylactic Allergies
*
Yes
No
Asthma
*
Yes
No
Diabetes
*
Yes
No
Epilepsy/Seizures
*
Yes
No
Hearing Problems
*
Yes
No
Vision Problems
*
Yes
No
If you answered yes, to any of the above, please explain and list what accommodations we should consider.
Please list any medications your child is taking:
*
Are there any other issues that are life threatening, require medication, or should be brought to our attention?
*
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Emergency Contacts and Insurance Information
Please provide us with the names of two people, other than yourself, who will be available to care for your child in case of an emergency.
Emergency Contact Name #1
*
First Name
Last Name
Emergency Contact Phone Number #1
*
-
Area Code
Phone Number
Relationship to Student
*
Emergency Contact Name #2
*
First Name
Last Name
Emergency Contact Phone Number #2
*
-
Area Code
Phone Number
Relationship to Student
*
Primary Care Physician's Name
*
First Name
Last Name
Primary Care Physician's Phone Number
*
-
Area Code
Phone Number
Dentist's Name
*
First Name
Last Name
Dentist's Phone Number
*
-
Area Code
Phone Number
Insurance Company
*
Group Number
*
Policy Number
*
Name of Insured
*
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Permission Forms
All information is confidential.
Medical Release
In the event of an emergency, I hereby give permission for any and all medical and/or dental attention to be administered to my child, in the event of an accident, injury, sickness, etc. I also assume the responsibility for the payment of any such treatment. I acknowledge that Kehillah High is unable to administer any medications, unless prior written authorization from the parent or guardian is obtained.
Yes
No
Liability Waiver
I hereby release Kehillah High, its officers, agents, and employees from all liability for injuries, illness or property damage resulting from my student's participation in all Kehillah High programs, including school and youth group activities, and agree to not make any claim or demand against Kehillah High for any or all losses or damages to student's person or property.
Yes
No
Photograph Permission
I give permission to use photographs or videos of my child(ren) on the Kehillah High website or other publicity materials for educational and advertising purposes.
Yes
No
Authorization
I acknowledge that the information on these forms is accurate and can be used in the care of my child in case of an emergency, and that I have read and understood all waivers and release information.
Parent/Guardian Signature
Clear
Submit
Should be Empty: