Adat Shalom-Beth Achim Learning Community Registration 2017-2018
Tuition:

Pre-K (3 & 4 year olds), K, and 1st grade — Members: No cost; Non-members: $825

Grades 2-7 — Members: $1100; Non-members: $1850

Limited scholarship is available. Open the Education Scholarship Form 2017-2018 by clicking here: http://adatshalom.org/wp-content/uploads/2017/03/scholarship-17-18.pdf

A deposit is required for each student in order to be placed in a class. If you register on or before July 14, 2017 you will qualify for the early bird discount. This $50.00 discount is taken off of the deposit for each child registered.

Welcome to our registration form.
If you have questions, please contact us at 248-626-2153 or email sshapiro@adatshalom.org
Contact Information
Street Address
Your answer
City/State/Zip
Your answer
Parent 1 Name
Your answer
Parent 1 Email
Your answer
Parent 1 Cell Phone
Your answer
Parent 2 Name
Your answer
Parent 2 Email
Your answer
Parent 2 Cell Phone
Your answer
Parent Marital Status
Child(ren) live(s) with:
If Parent 2 has a different address, please enter it below
Street Address
Your answer
City/State/Zip
Your answer
Student 1 Information
Student 1 Name
Your answer
Student 1 Hebrew Name
Your answer
Student 1 Gender
Student 1 Birthdate
MM
/
DD
/
YYYY
Student 1 Dietary Needs (check all that apply)
Required
Student 1 Entering Grade in Fall 2017
Student 1 School
Your answer
Student Educational Information - Student 1
Required
Student 2 Information
Student 2 Name
Your answer
Student 2 Hebrew Name
Your answer
Student 2 Gender
Student 2 Birthdate
MM
/
DD
/
YYYY
Student 2 Dietary Needs (check all that apply)
Student 2 Entering Grade in Fall 2017
Student 2 School
Your answer
Student Educational Information - Student 2
Student 3 Information
Student 3 Name
Your answer
Student 3 Hebrew Name
Your answer
Student 3 Gender
Student 3 Birthdate
MM
/
DD
/
YYYY
Student 3 Dietary Needs (check all that apply)
Student 3 Entering Grade in Fall 2017
Student 3 School
Your answer
Student Educational Information - Student 3
Student 4 Information
Student 4 Name
Your answer
Student 4 Hebrew Name
Your answer
Student 4 Gender
Student 4 Birthdate
MM
/
DD
/
YYYY
Student 4 Dietary Needs (check all that apply)
Student 4 Entering Grade in Fall 2017
Student 4 School
Your answer
Student Educational Information - Student 4
Emergency and Medical Information
Emergency Contact 1 Name
Your answer
Emergency Contact 1 Cell Phone
Your answer
Emergency Contact 1 Relationship to Student(s)
Your answer
Emergency Contact 2 Name
Your answer
Emergency Contact 2 Cell Phone
Your answer
Emergency Contact 2 Relationship to Student(s)
Your answer
In addition to parents and emergency contacts, to whom may the students be released?
Your answer
Physician
Your answer
Physician Phone Number
Your answer
Health Insurance Provider
Your answer
Policy Number
Your answer
Group Number
Your answer
Are all children fully immunized?
If the answer to the previous question was "no," please specify which child and explain:
Your answer
Please list any allergies or medical concerns, being sure to indicate the child's name if you are registering more than one child for school.
Your answer
Please list any medications taken, being sure to indicate the child's name if you are registering more than one child for school.
Your answer
Parent Learning Opportunities
I would like to get involved
Required
Which topics of adult learning are you interested in?
Required
I would attend sessions:
Required
Consent and Authorization
Each named child has my permission to attend and participate in the scheduled activities of the Religious School and Youth Department. The Adat Shalom-Beth Achim Learning Community has permission to transport each named child by bus or arrange a parent-driven carpool during religious school hours on scheduled trips and during informal youth activities after school. I understand that I will be informed in advance of these scheduled trips.
I have discussed with each named child all of the rules and regulations (Brit Kavod) established by the Adat Shalom-Beth Achim Learning Community relating to individual conduct in the school.
I authorize the school to engage appropriate health care providers to administer, prescribe and/or direct the administration of any emergency medication, medical treatment, care, surgery, hospitalization or medical procedures and services deemed appropriate under the circumstances if you are not able to contact me for instruction in a timely fashion. There are no exceptions or limitations, or other special instruction, in connection with the foregoing.
I agree to indemnify and hold Adat Shalom (and its personnel) free and harmless from any and all liability, charges, claims, costs, and expenses of every kind and nature whatsoever in connection with the provision of medical care pursuant to the above paragraph.
I represent to you that I have sole, full and legal power and right to execute this Consent, and that you will rely on my representations.
If this Consent is signed by more than one person, all references of the singular shall include the plural, jointly and severally.
If we publish a school directory, it will include the class, the teacher’s name, the student’s name, the parents’name(s), email address, mailing address, cell and home phone numbers. If a student lives at two households both sets of information will be included.
I/We give Adat Shalom-Beth Achim Learning Community and Adat Shalom Synagogue permission to use names and/or pictures of our student(s) in the Jewish News, synagogue media wall, social media, and other advertising.
I understand that I am paying a deposit toward tuition (if it is due) and will receive a complete statement
I'd like to apply for scholarship assistance.
I declare that I have read and fully understand the importance and effect of the foregoing consent form. Please type your full name as an electronic signature.
Your answer
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