Kesher Registration

Kesher Registration
Welcome to Kesher and Nesiah registration!

Click here to learn more about Kesher and here to learn more about Nesiah.

Early-bird and sibling discounts available upon payment!

Parent Guardian Information
Name *

First Name Last Name
Email *
example@example.com
Phone Number *
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Is there a second parent/guardian? *

Yes No
Name *

First Name Last Name
Email *
example@example.com
Phone Number *
Address (if different from first parent/guardian)

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Child Information
How many students are you registering? *
Child 1
Name *

First Name Last Name
Email (if applicable)
example@example.com
Mobile Number (if applicable)
School attending in Fall 2022 *
Grade entering in Fall 2022 *
Date of Bar/Bat Mitzvah (if applicable)

Month Day Year
Please share any allergies or medical information that may be relevant to learning at Kesher and Nesiah (if none, write "N/A") *
If your child has an IEP of 504, please share what learning accommodations are made for this child (if none, write "N/A") *
Child 2
Name *

First Name Last Name
Email (if applicable)
example@example.com
Mobile Number (if applicable)
School attending in Fall 2022 *
Grade entering in Fall 2022 *
Date of Bar/Bat Mitzvah (if applicable)

Month Day Year
Please share any allergies or medical information that may be relevant to learning at Kesher and Nesiah (if none, write "N/A") *
If your child has an IEP of 504, please share what learning accommodations are made for this child (if none, write "N/A") *
Child 3
Name *

First Name Last Name
Email (if applicable)
example@example.com
Mobile Number (if applicable)
School attending in Fall 2022 *
Grade entering in Fall 2022 *
Date of Bar/Bat Mitzvah (if applicable)

Month Day Year
Please share any allergies or medical information that may be relevant to learning at Kesher and Nesiah (if none, write "N/A") *
If your child has an IEP of 504, please share what learning accommodations are made for this child (if none, write "N/A") *
Child 4
Name *

First Name Last Name
Email (if applicable)
example@example.com
Mobile Number (if applicable)
School attending in Fall 2022 *
Grade entering in Fall 2022 *
Date of Bar/Bat Mitzvah (if applicable)

Month Day Year
Please share any allergies or medical information that may be relevant to learning at Kesher and Nesiah (if none, write "N/A") *
If your child has an IEP of 504, please share what learning accommodations are made for this child (if none, write "N/A") *

Other Information
Please help us strengthen our program(s) by selecting at least one volunteer opportunity

Be on the Education Committee (attend quarterly meetings and help guide current and future programming) Be a room parent (send an occasional email/text to your child’s class to help facilitate communication between Kesher and parents) Volunteer at a holiday program (High Holidays, Sukkot, Chanukah, Purim, and/or Passover) Host a Sukkot gathering in your family’s sukkah Host a Kesher event at your home (opportunities may include Shabbat dinner or Havdallah)
May we share your contact information with other parents? *

Yes No
Are your children up to date on school-mandated vaccines? *

Yes No
I hereby grant permission for my child(ren) to fully participate in all activities of the Ahavath Achim Synagogue. I understand that field trips will be adequately supervised. Transportation will be arranged by parent carpools, employees of the Ahavath Achim Synagogue, school buses, or walking. I will be informed beforehand of all such trips. I agree to indemnify and hold the synagogue and the employees harmless from any claim, cause of action, and/or liability that might result from my child traveling with an employee of the synagogue. *
Electronic Signature
As the parent/guardian of the child(ren) named above, I hereby give permission for the child to receive first aid, emergency medical transportation and emergency medical treatment (including x-ray examination, anesthetic, medical or surgical diagnosis) while in the care of Ahavath Achim Synagogue/HomeBeis@AA and its’ employees. I understand that I will be responsible for all costs incurred as a result of an emergency medical situation while my child is in the care of Ahavath Achim Synagogue/HomeBeis@AA. *
Electronic Signature
As the parent/guardian of the child(ren) named above, I grant permission for my child(ren) to participate in youth education programs at Ahavath Achim as part of HomeBeis@AA. My signature hereby releases and forever discharges Ahavath Achim Synagogue and its officers, trustees, employees, advisors, coordinators, chaperones, agents and their respective heirs at law, legal representatives, successors and assigns from any and all claims, demands, damages, actions, causes of action, suits and liabilities of every kind and nature, arising out of, resulting from, or relating to any incidents that may occur during these programs, including but not limited to any bodily injury to such child. *
Electronic Signature
I hereby grant permission to Ahavath Achim Synagogue and its representatives to photograph and/or video record my child(ren) and any adults in our family at events sponsored by Ahavath Achim Synagogue/HomeBeis@AA and to publish said photos or videos in any Synagogue publication, including social media and/or local Atlanta publications. *
Electronic Signature

Payment
How many children are you enrolling in Gan @Kesher (3 years old and Pre-K)?
How many children are you enrolling in Kesher (Grades K-1, or Sundays only, no Hebrew)?
How many children are you enrolling in Kesher (Grades 2-6, includes mid-week online Hebrew) or Nesiah (Grades 7-8; includes year-end trip to New York)
If you are a non-member, please check this box. There is a $100 per family fee to register as a non-member.
Would you like to include a donation for teachers’ holiday and year-end gifts? Suggested donation is $18 per student, but any amount is welcome.

Yes, I would like to donate $18
Select the discount code for which you are eligible (you may only select one)

EARLYBIRD22 - registering before Thursday, June 30 SIBLING22 - registering more than one child EARLYSIBLING22 - registering more than one child before Thursday, June 30
Subtotal
How would you like to pay? *

Credit Card Check Pay 50% now and 50% in December Pay monthly
TOTAL
Includes Convenience Fee (3% of Total)

Payment *

USD

Credit Card
First Name	Last Name
Credit Card Number	Security Code
Expiration Month	Expiration Year
Billing Address
Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Someone will follow up with you soon regarding your remaining payment.
Name of person submitting this form *

First Name Last Name
Email for receipt *
example@example.com
Should be Empty:

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