Jackson Religious School Admission form

Date *

Date

Applicant's Information

Child's Last Name *

Child's First Name *

M.I.

Birth Date *

Date

Gender *

Child's Age *

Hebrew Name *

Home Address

Home Street Address *

Home Street Address Line 2

City *

State *

Zip Code *

Home Phone Number *

- Area Code Phone Number

Student's Present School (Daytime School)

School Name

Student's Grade (2017-2018)

Parent's Information

Parent Last Name *

Parent First Name *

Primary Phone Number *

- Area Code Phone Number

E-mail Address *

Occupation

Employer

Parent's Information

Parent Last Name

Parent First Name

Phone Number

- Area Code Phone Number

E-mail Address

Occupation

Employer

Parents Marital Status

Married Divorced Separated Deceased: Parent Single

With whom is student living?

DISMISSAL INFORMATION

My child will be picked up by (please list as many as applicable) *

My child has permission to walk home alone after Religious School on

Monday Wednesday Saturday Monday, Wednesday & Saturday

IF PARENTS UNREACHABLE IN EMERGENCY, CALL

Name *

Phone Number *

- Area Code Phone Number

Do you grant permission to Sutton Place Synagogue to use your child’s photograph on its website or in other official printed publications as long as your child is not identified by name?

Yes No

Please indicate which Religious School track your child will be registered for:

Wednesday (only for Kindergarten – 2nd Grade): $1400 Monday/Wednesday (only for 3rd – 6th grade): $2500 Kitah Zayin Seminar (only for 7th grade): $2500 Wednesday/Shabbat School (only for 3rd – 6th Grade): $2500 Wednesday/Tutoring Track (only for 3rd-6th grade) Speak with Lesley

Placement of children in a particular class is at the discretion of our Religious School Principal. I release Sutton Place Synagogue from all responsibilities other than supervised school activities. It is understood and agreed that designees of the principal may photograph, film, videotape, audiotape or reproduce written materials of the applicant for use in publications and publicity. If and when the need for medical and/or surgical attention arises during the period of my child"s official participation in the Jackson Religious School program, I hereby grant permission for my child to be transported by private vehicle or ambulance to an appropriate medical facility and to be treated by qualified medical authorities at their discretion and that of the program leaders.

Medical Release Form

NON-PRESCRIPTION MEDICATIONS

My child has my permission to take the following non-prescription medications:

TYLENOL (acetaminophen) for headache?

Yes No

ADVIL (ibuprofen) for inflammation or pain (e.g. sprains)?

Yes No

Antacids (e.g. Tums/Mylanta) for indigestion?

Yes No

Decongestant and/or cough suppressants (e.g. Robitussin/Sudafed)

Yes No

Does your child suffer from any allergies? (e.g. bee sting, medications, etc.)

Yes No

If yes, please explain

In our effort to create an effective and positive learning environment for our students and classes, please provide the following confidential information.

Does your child have any psychological, behavioral, or learning issues that impact schooling? Please explain below.

Has your child been subject to severe disciplinary action (such as being suspended or expelled), from regular school, Jewish school, or camp setting? Please explain below.

Please list any prescription medicine your child takes:

Physicians Name

Number

Address

If and when the need for medical and/or surgical attention arises during the period of my child"s official participation in the Jackson Religious School program, I hereby grant permission for my child to be transported by private vehicle or ambulance to an appropriate medical facility and to be treated by qualified medical authorities at their discretion and that of the program leaders.

Parent's Signiture

Last Name *

First Name *

Date *

Date

Parent's Email *

I am submitting payment *

for my child who attends RS ONE day per week $ 1,400.00

for my child who attends TWO days per week/Kitah Zayin Seminar $ 2,500.00