K.U.L.A.M. Student Registration/Skill Summary Form - 2018-2019 School Year
Kids Understanding and Learning At Mount Zion - An inclusive program for students enrolled in classes at Mount Zion Temple as well as Youth Group and Retreats.

The information submitted on this page will remain strictly confidential. The only people who will view the information will be Sue Summit, Religious School Director, and Stuart Bloom, K.U.L.A.M. Coordinator. They will communicate specific strategies to teachers and advocates that will be useful in providing a successful education for your child.

Full Name of Student *
Your answer
Home Address *
Your answer
Date of Birth
MM
/
DD
/
YYYY
City, State, Zip *
Your answer
Other household members *
Name Relationship Age
Your answer
Parent/Guardian 1 Name *
Your answer
Parent/Guardian 1 cell phone *
Your answer
Parent/Guardian 1 email address
Your answer
Parent/Guardian 2 Name
Your answer
Parent/Guardian 2 cell phone
Your answer
Parent/Guardian 2 email address *
Your answer
Student's school *
Your answer
Grade *
Placement in school *
If you child receives special servicing please explain below:
Your answer
Prior religious education *
Doctor's Name, Address and Phone number *
Your answer
Please list any allergies you child has *
If you child does not have allergies please enter "None".
Your answer
Does your child take any medications? If no, please enter "None". *
If yes, please state the name of the medication and it's purpose.
Your answer
Describe student's general health. *
Your answer
Describe student's abilities and limitations including any pertinent information that would be useful in school planning and B'nai MItzvah preparation. *
Your answer
Does you child have seizures? If no, please enter "No". *
If yes, please describe how you would like school personnel to heandle them in the even a seizure occurs in school.
Your answer
Does you child receive any professional guidance or any type of therapy? *
If no, enter "No". If yes, please describe below.
Your answer
How does your child behave when unhappy or confused? *
Your answer
What behavioral approaches do you find useful? *
Your answer
Are you using any particular strategies which you would like used at Mount Zion during religious school? *
If no, please enter "No". If yes, please ellaborate below.
Your answer
My child is (check all that apply) *
Required
Does your child (check all that apply) *
Required
Can your child use the bathroom independently? *
How does your child communicate? (Check all that apply) *
Required
Additional comments regarding behavioral data that you would like to provide. *
If no additional comments, please enter "None".
Your answer
Please describe your goals in having your child enrolled in Religious School. *
Your answer
Will your child be able to attend Religious School regularly? *
Is student able to read English? *
Is student able to comprehend what they read? *
Is student able to comprehend what they hear? *
Is student UNABLE to write or print? *
Please describe student's best mode(s) of learning including any successful teaching strategies, particulary in the areas of listening skills, performing specific tasks, following directions, concept building and group discussion skills. *
Your answer
Please share your opinion as to the type of service delivery appropirate for the student as well as support services that will be needed. *
For example, modified curriculum, one on one advocate, teacher awareness, etc
Your answer
If your child has relevant medical, psychological and education evaluation or individuallized educational plans (IEPs) please make copies and submit them to the office at Mount Zion in an envelope addressed to SUE SUMMIT.
If you would like Sue Summit, Religious School Director, to call or email you please indicate below with your preference for communication.
Submit
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