Registration for Educational Programming 2021/2022

BSI Registration

for the 5785 - 2024/2025 Year!
Student Information
BSI Registration is open to students K-8th grade.

Our Wednesday program will have instruction for students K-5th grade.

If your child is in 6th, 7th or 8th grade and being tutored for their Bar/Bat Mitzvah, please register them for BSI, and we will create a personalized tutoring schedule for them.
Student Name 1*

First NameLast Name
Student's Hebrew Name 1
Birth Date*

MonthDayYear
Gender*

MaleFemaleOther
Incoming Secular School Grade*
Student Name 2

First NameLast Name
Student's Hebrew Name 2
Birth Date

MonthDayYear
Gender

MaleFemaleOther
Incoming Secular School Grade
Student Name 3

First NameLast Name
Student's Hebrew Name 3
Birth Date

MonthDayYear
Gender

MaleFemaleOther
Incoming Secular School Grade
Parent/Guardian Information
If there are any changes in address, phone number, or in who has authorization to pick up your child from educational programming throughout the course of the year, please contact Rabbi Rotenberg at rabbi@bzcongregation.com.
Parent/Guardian 1*

First NameLast Name
Cell Phone*

Area CodePhone Number
E-mail*
Parent/Guardian 2

First NameLast Name
Cell Phone

Area CodePhone Number
E-mail
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Please list other people and their relationship to your child who are authorized to pick them up from Beit Sefer Ivri:
Emergency Information
If Parent or Guardian cannot be contacted:*

First NameLast Name
Relationship*
Cell Phone*

Area CodePhone Number
Does your child have any medical concerns (medications, inhalers, epi pens, etc.)? Please be specific.*
Does your child have any allergies? Please be specific.*
Photograph/Video Release
I hereby give permission to use the photograph/video of the minor(s) named above for publicity, promotion, news release, videos and web use of our school and our congregations. This also applies to the written composition or visual art of the minor if it is published.*

We give permissionWe DO NOT give permission
Our programming recognizes the importance of ensuring the success of each student.

All information you share will be kept strictly confidential.
If your child has been identified as benefiting from special needs attention (an IEP, ADD/ADHD, speech and language, developmental delays, etc.), please indicate below. Someone will reach out to you to discuss how we can best serve your child's needs.*

YesNo
Registration Cost:

For one child: $225
For each additional child: $150

If your family needs assistance, please contact Rabbi Rotenberg. No child will be turned away!
Payment Method*

I will call the office with a credit card.I am sending a check in the mail.I am interested in a payment plan.
We can't wait to see you in August!
Should be Empty:

BSI Registration

Student Information

Parent/Guardian Information

Emergency Information

Photograph/Video Release

Our programming recognizes the importance of ensuring the success of each student.

We can't wait to see you in August!