Gersten School Registration 2016-2017
School fees are requested prior to the first day of class (9/11/16). If you need assistance, contact Rinat or Rabbi Manhoff.
Child's first name
Your answer
Child's last name
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School grade in August 2016
Child's street address
Your answer
Parent/Guardian
Your answer
Parent/Guardian's email address
Your answer
Parent/Guardian's phone number
Your answer
Parent/Guardian
Your answer
Parent/Guardian's email address
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Parent/Guardian's phone number
Your answer
Emergency contact's name and relation
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Emergency contact's phone number
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Out of state emergency contact's name and relation
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Out of state emergency contact's phone number
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Doctor's name
Your answer
Doctor's phone number
Your answer
Medical insurance and policy number
Your answer
Known allergies
Your answer
Medications (include dosage)
Your answer
Known learning needs
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Anything else we should know
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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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