Langley Jewish Supplementary School Registration Form

Langley Jewish Supplementary School Registration Form
Langley Jewish School is a welcoming and inclusive community school dedicated to fostering a love of Jewish culture and religion, Hebrew language acquisition, celebration of Israel, as well as Jewish art and music. For children 5 to 11 years old.

Langley Jewish School is presented by Connect Me In and Jewish Federation of Greater Vancouver in cooperation with local families.

Dates: April 15 & 29, May 13 & 27, June 10 & 17

Time: 2:30 to 5:00 p.m.

Location: Fort Langley Lions Hall Lower Hall (around back, by the parking lot) 23022 88 Ave, Langley, BC V1M

Cost: $60/1 student, $100/2 students, $120 3 students (all must be from one family)

Plus, please join us May 25 for Family Kabbalat Shabbat potluck. Details to come.

If you need a paper form, please contact Orly at ONaim@jewishvancouver.com.

Please complete all fields so that in case of emergency we can best care for your child. Thank you for your attention to this matter.
Student Information
Student Name 1

First NameLast Name
Birth Date

MonthDayYear
School Name
School Grade
- Student Name 2
  
  First NameLast Name
- Birth Date
  
  MonthDayYear
- School Name
- School Grade
- Student Name 3
  
  First NameLast Name
- Birth Date
  
  MonthDayYear
- School name
- School Grade
- Parent/Guardian Information
- Parent/Guardian 1*
  
  First NameLast Name
- Address 1*
  
  Street Address
  
  Street Address Line 2
  
  CityProvince
  
  Postal Code
- E-mail 1*
- Home Phone 1
  
  Area CodePhone Number
- Cell Phone 1*
  
  Area CodePhone Number
- Is the above contact information the same for the student(s) you are registering??
  
  YesNo (Please fill out the student address section below)
- Student Address
  
  Street Address
  
  Street Address Line 2
  
  CityProvince
  
  Postal Code
- Student Email
  example@example.com
- Student Phone Number
  
  Area CodePhone Number
- Parent/Guardian 2
  
  First NameLast Name
- All contact information is the same as Parent / Guardian 1 above
  
  Yes
- Address 2
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal Code
- E-mail 2
- Home Phone 2
  
  Area CodePhone Number
- Work Phone 2
  
  Area CodePhone Number
- Cell Phone 2
  
  Area CodePhone Number
- Child residing with
- Emergency Information
- Physician's Name
- Phone Number
  
  Area CodePhone Number
- If Parent or Guardian cannot be contacted:
  
  First NameLast Name
- Relationship
- Home Phone
  
  Area CodePhone Number
- Cell Phone
  
  Area CodePhone Number
- Work Phone
  
  Area CodePhone Number
- Emergency Medical Treatment
- I understand that I will be notified in the case of a medical emergency involving my child. In the event that I cannot be reached, I authorize the calling of a doctor and the providing of necessary medical services in the event my child is injured or becomes ill.*
  
  We AuthorizeWe DO NOT Authorize
- Alternate Pick Up
- Please list those people in addition to parents/guardians who are permitted to pick up your child:
- Field Trip
- I give permission for my child to participate fully in all activities of the Langley Hebrew School for the April – June 2018 school year. I understand that field trips will be adequately supervised, and transportation arranged either by parent carpools or walking, and that I will be informed beforehand of all such trips. I hereby empower the Hebrew School staff person to act for me in accordance with his/her best judgement in case of an emergency.*
  
  We AuthorizeWe DO NOT Authorize
- Photograph/Video Release
- I hereby give permission for my child to be photographed during the I understand the photos will be used to keep a journal of activities, to share during power point presentations and/or reports to our donors and for promotional purposes including flyers, brochures, newspaper and on the internet.*
  
  We give permissionWe DO NOT give permission
- We can serve your child best if we know about your child:
  
  All information you share will be kept strictly confidential
- Does your child have any medical concerns (allergies, medications, etc.)? Please be specific.
- Does your child have any learning issues that we should be aware of (ADD, ADHD, speech and language, dyslexia, developmental delays, etc.)?
- Is there anything else you think we should know about your child (temperament, strengths, friends, etc.)?
- Does your child have an IEP (Individual Education Plan) plan at his/her public school?
  
  YesNo
- Payment
  
  Thanks to the generosity of the Vancouver Jewish Federation, fees for this program are highly subsidized. Tuition for six sessions is $60 per student, with discounts for multiple children. Students must be registered and have their fees paid before the first day of class.
- Please submit your payment today at http://www.jewishvancouver.com/langley-hss2018
- Copy the above payment link into a new browser window.
- Once you have completed this form, please click on the submit button below.
- Should be Empty:

Langley Jewish Supplementary School Registration Form

Student Information

Parent/Guardian Information

Emergency Information

Emergency Medical Treatment

Alternate Pick Up

Field Trip

Photograph/Video Release

We can serve your child best if we know about your child:

Payment

Copy the above payment link into a new browser window.

Once you have completed this form, please click on the submit button below.