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.)
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Please bill me
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