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2017-2018 Registration Form Simcha Learning Center at Riverdale Temple

Email address *
Untitled Title
Parent/Guardian #1 First and Last Name *
Your answer
Parent/Guardian #1 Email Address *
Your answer
Parent/Guardian #2 First and Last Name *
Your answer
Parent/Guardian #2 Email Address *
Your answer
Parent/Guardian #1 address *
Your answer
Parent/Guardian #2 address if different *
Your answer
Parent/Guardian #1 cell number *
Your answer
Parent/Guardian #2 cell number *
Your answer
Is your family a member at Riverdale Temple *
Emergency contact name and number other than parent/guardian *
Your answer
PHOTO RELEASE FORM : From time to time, RT may use your child’s name, likeness, voice, statements, and other information supplied by him/her in a variety of synagogue publications , including but not limited to: Newsletter, Weekly Calendar, Fliers, RT website (both photos and mini videos without individual identification on public facing side of the site, but with names on the password-protected site). This use relates solely to photographs, statements, and videotape made during your child’s participation in RT sponsored activities. Please check your preference. *
Volunteer: Check off all that apply
Child's Last Name *
Your answer
Child's First Name *
Your answer
Child's Hebrew Name *
Your answer
Child's Birthday (update year) *
MM
/
DD
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YYYY
Child's Grade in school in September 2018 *
Your answer
Child's School and phone number *
Your answer
Child's allergies or medical information *
Your answer
Is your child interested in participating in Junior Choir before school on Sundays from 9:00am - 9:30am (starting in October)? *
Does your child have an IEP or 504? *
Child # 2
If you are only registering one child please scroll down to "Additional Information"
Child's Last Name
Your answer
Child's First Name
Your answer
Child's Hebrew Name
Your answer
Child's Birthday (update year)
MM
/
DD
/
YYYY
Child's Grade in school in September 2018
Your answer
Child's School and phone number
Your answer
Child's allergies or medical information
Your answer
Is your child interested in participating in Junior Choir before school on Sundays from 9:00am - 9:30am (starting in October)?
Does your child have an IEP or 504?
Child # 3
If you are only registering one child please scroll down to "Additional Information"
Child's Last Name
Your answer
Child's First Name
Your answer
Child's Hebrew Name
Your answer
Child's Birthday (update year)
MM
/
DD
/
YYYY
Child's Grade in school in September 2018
Your answer
Child's School and phone number
Your answer
Child's allergies or medical information
Your answer
Is your child interested in participating in Junior Choir before school on Sundays from 9:00am - 9:30am (starting in October)?
Does your child have an IEP or 504?
Please use this space to provide any addition information you would like to share about your child/ren, family, or your hopes for Riverdale Temple and the upcoming school year. All information is confidential and will not be shared without your approval.
Your answer
Tuition and Membership Fees
To enroll at the Simcha Learning Center you must be Riverdale Temple members.
Membership and tuition fees are outlined below:

Please note:

1) If you are enrolling more than one child in the Simcha Learning Center, your membership fee corresponds to the grade of your eldest child enrolled in the program.

2) All fees are contingent on your ability to pay; no one will be turned away because of financial difficulties. If you would like to make alternate arrangements (i.e., a further reduced rate and/or payment plan), please reach out to Dorothy Kay or Susan Birnbaum, our financial secretaries, who will work out special, confidential arrangements with you for payment of all fees.

Dorothy Kay

Susan Birnbaum

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