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

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
I agreeI do not agree and understand that I can not leave my children in the building without a parent present.
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
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 AgreeI disagree
I agree.I do not agree and will further discuss this with the Rabbi and/or the President.
I agree
Parent Signature*

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Date*

MonthDayYear
Date
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General Information