STUDENT ENROLLMENT FORM
2020-2021/JEWISH YEAR 5781
SCHOOL INFORMATION
School times:
First Sunday and all Sundays by Zoom:
August 23 starting by Zoom (calendar: https://docs.google.com/document/d/1pet-jf2E4UO5G6yaUeuaUcwYsWRhin-F2mCsbbr99Qo/edit?usp=sharing)
Times: 9:30-11:30 (Ganon 9:30-10:30)

When in person again:
Sunday 9:30-12:30
Last Sunday of the month: Lunch at 12:30 and catch-up class by appointment

Cost:
LEC: early childhood through 10th grade (including madrichim)
First child: $370
Second child: $334
Third child: $295

Student leadership: 11th and 12th graders (T.A. program)
Per student: $120

Kadima (5th - 8th grades)
Per student: $15
plus event costs
USY (9th - 12th grades)
Per student: $20
plus event costs
Student Information
Student 1 Last Name *
Student 1 First Name *
Student 1 Hebrew/Jewish Name *
(If currently unknown, please state "unknown" to proceed. We will need the name for class.)
Student 1 Grade as of 8/01/2020 *
Student 1 Date of Birth *
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Student 1 School/School District *
Student 1 Youth Group (Kadima or USY) *
Required
Student 2 Last Name,
Student 2 First Name
Student 2 Hebrew/Jewish Name
(If currently unknown, please state "unknown" to proceed. We will need the name for class.)
Student 2 Grade as of 8/01/2020
Clear selection
Student 2 Date of Birth
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DD
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YYYY
Student 2 School/School District
Student 2 Youth Group (Kadima or USY)
Student 3 Last Name
Student 3 First Name
Student 3 Hebrew/Jewish Name
(If currently unknown, please state "unknown" to proceed. We will need the name for class.)
Student 3 Grade as of 8/01/2020
Clear selection
Student 3 Date of Birth
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DD
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YYYY
Student 3 School/School District
Student 3 Youth Group (Kadima or USY)
PARENT INFORMATION
Parent 1 Last Name, First Name *
Parent 1 Street Address (see below for city, state, zip) *
Parent 1 City, State, Zip *
Parent 1 E-mail *
Parent 1 Cell Phone *
Parent 1 Home Phone (or type "none" if you don't have) *
Parent 1 Work Phone
Parent 2 Last Name, First Name
Parent 2 Street Address (see below for city, state, zip)
Parent 2 City, State, Zip
Parent 2 E-mail
Parent 2 Cell Phone
Parent 2 Home Phone
Parent 2 Work Phone
EMERGENCY INFORMATION
Emergency Contact Person (other than parent) *
Emergency Person's Cell Phone Number *
Emergency Person's Home Phone Number *
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 *
Visual or hearing *
Does your child need to wear glasses in class? Is there a hearing impairment the teacher should be aware of?
Learning or other needs *
Is there anything we should know about your child that will help us in the school, social, emotional, or learning.
Immunization Record MANDATORY
Please bring a copy your child/ren's immunization record to the office at your earliest convenience. You may also email a PDF or image of the card/s to the LEC director at lec@ahavathsholom.org.
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?
Clear selection
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."
Medical Release *
Please check "I AGREE" below to agree to the following statement: “ In the event of an emergency, I hereby give qualified medical personnel permission to secure proper treatment for my child, including, if necessary, hospitalization. I understand that I will be contacted immediately in such a case. ”
Required
PERMISSION FOR PHOTOGRAPHS AND PUBLICITY *
Please check "I AGREE" below to allow us to put pictures of your child(ren) on our 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.
PERMISSION FOR FIELD TRIPS *
Please check "I AGREE" below to give permission for my child to go on supervised field trips
HEBREW LEARNING
Would you be interested in an additional Hebrew learning hour on a Wednesday (vocabulary and/or reading practice)
Clear selection
PAYMENT *
How would you prefer to pay:
PAYMENT 2 *
First payment will be collected on September 1. Final payment May 1. How would you prefer to pay:
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. Congregation Ahavath Sholom does require that you have an up to date family membership. There may be some additional fees for additional activities, such as field trips or a program that is outside of our usual programming. I agree to the above and promise to pay all tuition, membership, and fees as stated. I know that if I have any questions or concerns, I may contact Pattie Wood, Administrator.
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. Congregation Ahavath Sholom does require that you have an up to date family membership. There may be some additional fees for additional activities, such as field trips or a program that is outside of our usual programming. I agree to the above and promise to pay all tuition, membership, and fees as stated. I know that if I have any questions or concerns, I may contact Pattie Wood, Administrator.
Today's date *
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