22-23 8-12th Gr Union County HaMakom Registration

UNION COUNTY HAMAKOM: The Place To Be

Community/Culture/Curiosity/Celebration

2022-2023 Registration Form

Welcome to Union County HaMakom! This teen program is for 8th through 12th Grade students affiliated with any of the Union County participating Temples. Classes meet on Tuesday evenings from 7:00-9:00 pm at Temple Emanu-El, 756 East Broad Street, Westfield, NJ.

Opening day is Tuesday, September 20 at Temple Emanu-El

Please complete the entire form.

Classes will be split into 4 mini-mesters as follows:

Mini-Mester 1

9/20 (Opening Day), 10/11 (Optional), 10/25, 11/1, 11/15

Mini-Mester 2

11/29, 12/6, 12/13, 12/20 (School wide Chanukah celebration), 1/3, 1/10

Mini-Mester 3

1/17 (School wide program), 1/31, 2/7, 2/14, 2/21, 2/28

Mini-Mester 4

3/7, 3/14, 3/21 3/28, 4/18 (School wide program), 4/25 (School wide program, 5/2, 5/9 (Last session-bonfire)

Tuition per mini-mester is $150 or $500 for all.

For detailed information please reach out to Samara Schwartz at sschwartz@tewnj.org.
Select the Temple at which you are a member. *

Congregation Beth Israel Temple Beth Ahm Yisrael Temple Beth-El Mekor Chayim Temple Beth Or/Beth Torah Temple Emanu-El/Westfield Temple Sha'arey Shalom Temple Sholom

STUDENT INFORMATION
Student's LAST Name *
Student's FIRST Name *
Student's MIDDLE Name
Student's Hebrew Name
Date of Birth *

Month Day Year
Student's Gender *
Student's Pronouns
(For example - she/her, he/him, they/them)
Secular School Grade as of September 2022 *
Name of Secular School *
Student's Primary Home Phone *
Student's Email (if your child does not have a unique email address of their own, please leave this question blank)
example@example.com
Student's Cell Phone Number
Student's Primary Home Address
Street Address *
City *
State *
Zip Code *

FAMILY INFORMATION

Please help us to get to know your family. Please note we will use the contact information to communicate. Parent/Guardian 1 should be the primary parent. If you do not wish for Parent/Guardian 2 to be contacted please DO NOT provide contact information.
All correspondence should be sent to *

Parent/Guardian 1 Both Parent/Guardian 1 and Parent/Guardian 2
Parent/Guardian 1: Last Name *
Parent/Guardian 1: First Name *
Parent/Guardian 1: Cell Phone *
Parent/Guardian 1: Would you like to be included in a text messaging app to receive real time information about HaMakom? *

Yes No
Parent/Guardian 1: Business Phone
Parent/Guardian 1: Home Phone (if different from student's home phone)
Parent/Guardian 1: Email Address *
example@example.com
Parent/Guardian 1: Address (if different from student's primary home address)

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Parent/Guardian 1: Occupation
Any special skills or interests you have that you would be willing to share with our students (knitting, art, writing, Israeli dance, etc.)
Parent/Guardian 2: Last Name
Parent/Guardian 2: First Name
Parent/Guardian 2: Cell Phone
Parent/Guardian 2: Would you like to be included in a text messaging app to receive real time information about HaMakom ?

Yes No
Parent/Guardian 2: Business Phone
Parent/Guardian 2: Home Phone (if different from student's home phone)
Parent/Guardian 2: Email Address
example@example.com
Parent/Guardian 2: Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Parent/Guardian 2: Occupation
Any special skills or interests you have that you would be willing to share with our students (knitting, art, writing, Israeli dance, etc.)
If parents or other family members have any special needs we should know about, please describe:

If your child has any special living arrangements, please describe:
Is there anything about your child or family that you feel we should know, please describe:
For example, divorce, ongoing illness, recent death in family, custody arrangements
What does your child do in the summer? If they attend CAMP (day or overnight), please provide the name of the CAMP. *

EMERGENCY CONTACT INFORMATION
EMERGENCY CONTACT NAME *
Must be someone other than parent/guardian listed above
EMERGENCY CONTACT RELATIONSHIP *
Example: grandparent, friend, neighbor, etc.
EMERGENCY CONTACT CELL PHONE NUMBER *
EMERGENCY CONTACT HOME PHONE NUMBER

LEARNING ACCOMMODATIONS

This information will help us do our best in providing your child with a safe, warm, creative and nurturing environment in which he/she will learn and achieve social and academic success. Please note that this information will be kept in confidence and shared only with the faculty who are directly responsible for your child's learning.

If you would like to connect to someone directly, please email the HaMakom Director, Samara Schwartz, at sschwartz@tewnj.org
Does your teen have any specialized learning needs of which we aught to be aware? Please enter NO, if there are none. *
Please explain:
Does your teen have an IEP? *

Yes No
Does your teen receive any of these accommodations? *

No Resource program Instructional Aide Special Education class Occupational Therapy Counseling
Please explain:
If your child requires special seating arrangements in the classroom, please describe:
Is there any other information that you would like to share to help us best meet the social and/or academic learning needs of your child?

STUDENT ENROLLMENT

Please select your child's grade.
PLEASE SELECT THE GRADE TO ENROLL YOUR CHILD *

8th Grade 9th Grade 10th Grade 11th Grade 12th Grade
STUDENT MINI-MESTER CHOICES

Tuition per Mini-Mester is $150 or $500 for all.
PLEASE SELECT THE MINI-MESTER(S) TO ENROLL YOUR CHILD *

Mini-Mester 1 (Septemer 1-Noveber 5) Mini-Mester 2 (November 29-January 10) Mini-Mester 3 (January 17-February 28) Mini-Mester 4 (March 1-May 9)

Thank you, please press submit below.
Should be Empty:

Student's Primary Home Address

FAMILY INFORMATION RELEASE: We may provide a small directory so you and your children can be in touch with one another outside of HaMakom. It will include your child's name, parent/guardian name, phone number, home address and parent/guardian email.

Thank you, please press submit below.