2018-19 Registration Form for the Rabbi Jacob H. Epstein School of Jewish Studies
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FIRST STUDENT'S INFORMATION
Student's First Name *
Your answer
Student's Last Name *
Your answer
Birthdate *
MM
/
DD
/
YYYY
Gender *
Grade *
Does the student have allergies or a medical condition? *
If yes, please include information to help us keep your student safe and best meet their needs.
Your answer
Has the student ever had any learning or behavioral modifications in the classroom? *
If yes, please explain so that we can best serve your student’s needs.
Your answer
Has your student ever received modifications in any learning environment, i.e. behavior modification, extended time, etc.? *
If yes, please describe.
Your answer
Would you like your student to receive modifications at Epstein?
The Epstein School would like to text your student reminders and updates. *
Student's cell number
Your answer
Student's email
Your answer
Student's Home Address *
Your answer
City *
Your answer
Zip Code *
Your answer
Home phone number
Your answer
Synagogue Affiliation *
Families not affiliated with a synagogue listed below pay the amount normally contributed by the synagogue towards tuition.
SECOND STUDENT'S INFORMATION
Student's First Name
Your answer
Student's Last Name (if different from your first student's)
Your answer
Birthdate
MM
/
DD
/
YYYY
Gender
Grade
Does the student have allergies or a medical condition?
If yes, please include information to help us keep your student safe and best meet their needs.
Your answer
Has the student ever had any learning or behavioral modifications in the classroom?
If yes, please explain so that we can best serve your student’s needs.
Your answer
Has your student ever received modifications in any learning environment, i.e. behavior modification, extended time, etc.?
If yes, please describe.
Your answer
Would you like your student to receive modifications at Epstein?
The Epstein School would like to text your student reminders and updates.
Cell Number
Your answer
Email
Your answer
Home Address and Phone
(if different from the first student's address)
Your answer
THIRD STUDENT'S INFORMATION
Student's First Name
Your answer
Student's Last Name (if different from the first student's)
Your answer
Birthdate
MM
/
DD
/
YYYY
Gender
Grade
Does the student have allergies or a medical condition?
If yes, please include information to help us keep your student safe and best meet their needs.
Your answer
Has the student ever had any learning or behavioral modifications in the classroom?
If yes, please explain so that we can best serve your student’s needs.
Your answer
Has your student ever received modifications in any learning environment, i.e. behavior modification, extended time, etc.?
If yes, please describe.
Your answer
Would you like your student to receive modifications at Epstein?
The Epstein School would like to text your student reminders and updates.
Cell Number
Your answer
Email
Your answer
Home Address and Phone
(if different from the first student's address)
Your answer
PARENT/GUARDIAN INFORMATION
Parent/Guardian #1 First Name *
Your answer
Parent/Guardian #1 Last Name *
Your answer
Parent/Guardian #1 Cell Number *
Your answer
Parent/Guardian #1 Email *
Your answer
Parent/Guardian #1 Full Address
(if different from the first student's address)
Your answer
Parent/Guardian #2 First Name
Your answer
Parent/Guardian #2 Last Name
Your answer
Parent/Guardian #2 Cell Number
Your answer
Parent/Guardian #2 Email
Your answer
Parent/Guardian #2 Full Address
(if different from the first student's address)
Your answer
Additional parent/guardian/significant adult information
Please include name(s), email(s), and phone number(s), if applicable.
Your answer
ADDITIONAL INFORMATION
I need a Payment Plan Form.
I need a Tuition Assistance Form.
I'd like to sponsor snack during break for $18 per night.
I'd like to sponsor an Epstein dinner or special event
I'd like to serve on the following sub-committee(s) of the Epstein Board of Directors
I'd like to volunteer in another capacity:
Your answer
Would you like Epstein's help in arranging car pools for your student(s)?
The Epstein School will share your contact information and address with others in your area
Unless instructed otherwise, Epstein may use photos for Epstein publicity, in the Jewish Observer, Epstein's web site and Facebook page, and other media. *
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