School Registration Form
Please complete the following information about your child.
Email address *
Child's Name (first and last name) *
Your answer
Birthdate *
MM
/
DD
/
YYYY
Parent/Guardian 1 Name
Your answer
Parent/Guardian 2 Name
Your answer
Email - Parent/Guardian 1 *
Your answer
Email - Parent/Guardian 2
Your answer
Phone - Parent/Guardian 1 *
Your answer
Phone - Parent/Guardian 2
Your answer
Address
Your answer
I would like my child placed with a friend (ONE name only)
Your answer
What grade will your child be entering in September 2018? *
Grades 3, 4 or 5 please check choice 1 AND choice 2. Efforts will be made to accommodate your first choice. Choices will be on a first come first serve basis. (For Skype please make it your choice 1 & 2) *
M 4:30 - 5:30
M 5:00 -6:00
Th 4:30 - 5:30
Th 5:00 - 6:00
Skype
N/A
CHOICE 1
CHOICE 2
Grades 6 please choose option:
Does your child have special medical or learning needs?
If yes, please provide details below.
Your answer
Does your child have food allergies?
If yes, please provide details below.
Your answer
Name of Insurance Carrier *
Your answer
Health Insurance Policy Number *
Your answer
Photo Release *
I grant permission to use any photographs and/or videos of my child taken at school for publicity and marketing purposes, both in print and online. I agree that neither I, nor my child will receive compensation for the use of any images.
Emergency Medical Release *
I hereby give my consent for Temple B'nai Or to make available to my child professional emergency medical care if such care is indicated. It is my understanding that a conscientious effort will be made to contact me before such action is taken. It is further understood that every effort will be made to contact my child's physician prior to any treatment. However, in the event that this is not possible, I give my permission for my child to receive proper medical care by any doctor, nurse, paramedic or member of a medical staff of a hospital licensed in the State of New Jersey.
Emergency Contact Name *
(Other than parents)
Your answer
Emergency Contact Phone Number *
Please enter your phone number like: ###-###-####
Your answer
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