Gersten School Registration 2017-2018
Please fill this out separately for each child who will be attending the Gersten School.
Email address *
Child's first name *
Your answer
Child's last name *
Your answer
School grade in August 2017 *
Child's street address *
Your answer
Parent/Guardian *
Your answer
Parent/Guardian email address *
Your answer
Parent/Guardian phone number *
Your answer
Parent/Guardian
Your answer
Parent/Guardian email address
Your answer
Parent/Guardian phone number
Your answer
Emergency contact's name and relation *
Your answer
Emergency contact's phone number *
Your answer
Out of state emergency contact's name and relation *
Your answer
Out of state emergency contact's phone number *
Your answer
Doctor's name *
Your answer
Doctor's phone number *
Your answer
Known allergies
Your answer
Medications (include dosage)
Your answer
Known learning needs
Your answer
Anything else we should know
Your answer
Permission to dispense acetaminophen *
Permission to dispense ibuprophan *
My student has my permission to participate in all Gersten Torah and Hebrew School sponsored activities. If there is any exception, and I do not want my student to participate, I will notify the staff in writing. In the event of an accident or medical emergency, and if I am unable to be contacted, Temple Beth Sholom staff is hereby authorized to act as my agent to secure emergency medical treatment. (Please "sign" below.) *
Your answer
Please bill me *
Submit
Never submit passwords through Google Forms.
reCAPTCHA
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Additional Terms