Temple Israel of the Poconos

Temple Israel of the Poconos

Religious School Registration Form
Today's Date

MonthDayYear
Date
General Information
Parent #1 name*

First NameLast Name
Parent #2 name*

First NameLast Name
Parent #1 Email*
example@example.com
Parent #1 Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Parent #2 Email*
example@example.com
Parent #2 Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Child #1 Name*

First NameLast Name
Child #1 Birth Date*

MonthDayYear
Child #1 Gender*
Child #1 grade for this upcoming Fall*
Child #1 Hebrew name*
Child #2 Name

First NameLast Name
Child #2 Birth Date

MonthDayYear
Child #2 Gender
Child #2 grade for this upcoming Fall
Child #2 Hebrew name
Child #3 Name

First NameLast Name
Child #3 Birth Date

MonthDayYear
Child #3 Gender
Child #3 grade for this upcoming Fall
Child #3 Hebrew name
Child #4 Name

First NameLast Name
Child #4 Birth Date

MonthDayYear
Child #4 Gender
Child #4 grade for this upcoming Fall
Child #4 Hebrew name
Child #5 Name

First NameLast Name
Student #5 Birth Date

MonthDayYear
Child #5 Gender
Child #5 grade for this upcoming Fall
Child #5 Hebrew name

Residence Information
Current Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian address If different from child(ren)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Emergency Contact Information
Child's Primary Emergency | Contact Name*

First NameLast Name
Primary Emergency | Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Primary Emergency | What is their relationship with this person?*

Medical Information
In the event of a major medical emergency and a parent is not present to authorize treatment, Temple Israel will call 911 and authorize treatment. If you do not agree with this, then you will not be able to leave your child(ren) in the building and you will have to stay for the entire Hebrew School session.*

I agreeI do not agree and understand that I can not leave my children in the building without a parent present.
Preferred Hospital:*

LVHNSt. Luke's
For each child, please list any of the following; current medications, medication allergies, food allergies, or chronic health concerns. Please be aware that your child will need to be responsible for knowing what foods he/she can or cannot eat. *

Enrollment History
Previous Religious School Name (if none, put N/A)
City
State
Please list how many years each child attended the previous religious school?
Date Started

MonthDayYear
Date
Date Ended

MonthDayYear
Date
Do your child(ren) have any learning disabilities, emotional and/or behavioral issues?*

YesNo
If you answered yes, please indicate below which child(ren) and describe their issues.
Please upload a copy of their IEP, if they have one, so that our teachers can be better prepared to assist your child(ren) in our classrooms. This registration form is HIPAA compliant and all your child's information will be kept confidential.

Cancelof
I give permission for Temple Israel (and outside news media) to photograph/video my child(ren) in the religious school or Temple Israel related activities and understand that some photographs may be displayed or used for advertising/marketing purposes including on our website and social media sites.*

I AgreeI disagree
I understand that the Temple Israel policy is that my child must have a total of 5 years of Hebrew School enrollment (either with us or somewhere else) to be Bar/Bat Mitzvahed at the age of 13. If my child does not fulfill this requirement, then a meeting with the Rabbi must occur before enrollment to discuss whether my child's Bar/Bat Mitzvah will be delayed.

I agree.I do not agree and will further discuss this with the Rabbi and/or the President.
I understand that I will be responsible to pay yearly dues to Temple Israel of the Poconos and because of that my child(ren) will receive a free religious school education. Furthermore, I understand that if I have arranged (with the Treasurer) for my dues to be on a payment plan, that I need to make the first payment before the first day of Religious school.*

I agree
Parent Signature*
Date*

MonthDayYear
Date
Should be Empty:

Temple Israel of the Poconos

General Information

Residence Information

Emergency Contact Information

Medical Information

Enrollment History