Sam S. Bloom Learning Center
STUDENT AND "MADRICHIM" ENROLLMENT FORM 2019-2020
SCHOOL INFORMATION
School times:
Sunday 9:15-12:15, Wednesday 4:15-6:15 (Grades 2-7 only)
Madrichim times: Sunday 9:15-12:15 (80% attendance required), Wednesdays optional, Grades 8-9
Last Sunday of the month: Lunch at 12:15 and catch-up class by appointment 12:45-1:45
Cost:
K-1: free tuition, $180 non-refundable registration fee, due at registration
Grades 2-7: $950 early bird (after July 1 $1,150) , 3rd sibling 50% discount, $180 per student non-refundable registration fee required at registration (will be subtracted from your total tuition due)
To receive the early bird rate, your registration must be date-stamped July 1 or earlier
Madrichim: $250
Please see the Sam S. Bloom Learning Center Handbook 2.0 for more information (link: https://docs.google.com/document/d/1sdV8X7qdeLST0nm4TovdclOgkpBAi36NBwxroxVNyPI/edit)
STUDENT INFORMATION
Student 1 Last Name, First Name (ex. Henning, Jaxon) *
Your answer
Student 1 Hebrew/Jewish Name *
(If currently unknown, please state "unknown" to proceed. We will need the name for class.)
Your answer
Student 1 Grade as of 8/01/2019 *
Your answer
Student 1 Date of Birth *
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Student 1 School/School District
Your answer
Student 2 Last Name, First Name
Your answer
Student 2 Hebrew/Jewish Name
(If currently unknown, please state "unknown" to proceed. We will need the name for class.)
Your answer
Student 2 Grade as of 8/01/2019
Your answer
Student 2 Date of Birth
MM
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DD
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YYYY
Student 2 School/School District
Your answer
Student 3 Last Name, First Name
Your answer
Student 3 Hebrew/Jewish Name
(If currently unknown, please state "unknown" to proceed. We will need the name for class.)
Your answer
Student 3 Grade as of 8/01/2019
Your answer
Student 3 Date of Birth
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YYYY
Student 3 School/School District
Your answer
Are any students above incoming 6th or 7th graders who do not have a Bar/Bat-Mitzvah date yet? *
If so, please pick 3 possible Bar/Bat-Mitzvah dates for that student, and please contact the office to make an appointment with Rabbi to discuss which date works best. The dates should be on or after the child's 13th birthday. These are just potential dates as a starting point for discussion (so don't worry :-). The dates should be Saturdays.
Required
Possible Date 1
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Possible Date 2
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Possible Date 3
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PARENT INFORMATION
Parent 1 Last Name, First Name *
Your answer
Parent 1 Address *
Your answer
Parent 1 E-mail *
Your answer
Parent 1 Cell Phone *
Your answer
Parent 1 Home Phone *
Your answer
Parent 1 Work Phone
Your answer
Parent 2 Last Name, First Name
Your answer
Parent 2 Address
Your answer
Parent 2 E-mail
Your answer
Parent 2 Cell Phone
Your answer
Parent 2 Home Phone
Your answer
Parent 2 Work Phone
Your answer
Child(ren) Residing With:
check all that apply
Which parent should receive e-mail communications (mainly weekly newsletters and progress reports)
check all that apply
Would any adult in your household like to register for the Hebrew Class for Parents/Adults?
check all that apply
EMERGENCY INFORMATION
Emergency Contact Person (other than parent) *
Your answer
Relationship to Student *
Your answer
Emergency Person's Cell Phone Number *
Your answer
Emergency Person's Home Phone Number *
Your answer
Doctor Name
Your answer
Doctor Phone
Your answer
Health Insurance Company
Your answer
Policy Number
Your answer
HEALTH AND EDUCATIONAL INFORMATION
This information is being requested in order to better serve your child. This information will be kept confidential and shared only with necessary staff. If you have more than one child enrolled, please indicate child 1, 2, or 3 per above. If there are no issues, please type "none" to proceed.
Allergies *
Your answer
Visual or hearing *
Does your child need to wear glasses in class? Is there a hearing impairment the teacher should be aware of?
Your answer
Learning or other needs *
Is there anything we should know about your child that will help us in the school, social, emotional, or learning. Our goal is to accommodate children with learning disabilities and behavior challenges. However, if a child needs an assistant to be in the classroom, the parents are responsible to provide for that assistant. We are happy to discuss with you the possibilities of working with your child. If your child has an IEP or other learning planning at their day school it can only help us to know some of the details of your child's learning challenges. Please let us know.
Your answer
Is it okay to share your e-mail address in a school directory? *
For 6th and 7th grade students only, is it okay to share your e-mail address with other 6th and 7th grade parents for Bar/Bat-Mitzvah invitations?
ADDITIONAL INFORMATION AND PERMISSIONS
Authorized Pick-Up *
Who may pick up your child(ren) other than parent(s)? If no one other than parents may pick-up please type "none."
Your answer
Medical Release *
Please check "I AGREE" below to agree to the following statement: “ In the event of an emergency, I authorize Ner Tamid Synagogue, its officers, agents and employees to administer first aid and/or transport my child(ren) to a physician or hospital, and I consent to emergency medical treatment for my child if a parent, guardian, or emergency contact cannot be reached.”
Required
LIABILITY WAIVER *
Please check "I AGREE" below to agree to the following statement: “I/we hereby release Ner Tamid Synagogue, its officers, agents, and employees from all liability for injuries, illness or property damage resulting from child’s participation in all department of education programs, including school and youth group activities , and agree not to make any claim or demand against them for any or all losses or damages to student’s person or property.”
Required
PERMISSION FOR PHOTOGRAPHS AND PUBLICITY *
Please check "I AGREE" below to allow us to put pictures of your child(ren) on our Ner Tamid Synagogue or Sam S Bloom Learning Center Facebook page or other publicity materials for educational and advertising purposes. Names and other identifying information will never be used. The weekly newsletter is distributed to school families and select synagogue members only.
PARENT 1 E-SIGNATURE *
Please e-sign /FIRST NAME LAST NAME/. Your e-signature indicates that you have read and agree to all of the above. Your signature also indicates that you agree to pay the non-refundable registration fee upon submission of this form. You may pay either by mailing a check, through your shulcloud account (www.nertamidsd.org/member/payment/php) or by contacting the office.
Your answer
PARENT 2 E-SIGNATURE
Please e-sign /FIRST NAME LAST NAME/. Your e-signature indicates that you have read and agree to all of the above. Your signature also indicates that you agree to pay the non-refundable registration fee upon submission of this form. You may pay either by mailing a check, through your shulcloud account (www.nertamidsd.org/member/payment/php) or by contacting the office.
Your answer
Today's date *
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