CAA Religious School Registration (Pre-K--12) 5783 (2022-23)

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Email *

Student Name *

Eg: Sarah Smith

Student Hebrew Name *

Eg: Sarah Hannah Bat Daniel v'Yona

Student Primary Street Address *

Zip Code *

Student Birthday *

YYYY

Parent/Guardian 1 Name *

Parent/Guardian 1 Email *

Parent/Guardian 1 Phone Numbers *

Eg: Cell: 518-555-5555; Home: 518-444-4444; Work: 518-333-3333

Parent/Guardian 2 Name

Parent/Guardian 2 Email

Parent/Guardian 2 Phone Numbers

Eg: Cell: 518-555-5555; Home: 518-444-4444; Work: 518-333-3333

Child lives with: *

If there is anyone else authorized to pick up your child from school please list their names, relationship to you, and emergency contact number where they can be reached *

Please help us by describing any emotional, behavioral, physical or learning challenges that might affect the student’s ability to work at grade level or participate in educational or social programs at CAA, or information that might be useful for the educational staff in planning for your child’s education. *

Does the student have an IEP or 504 plan? *

If yes a copy of the IEP must be received to the Religious School Office before the start of the school year.

Yes

Describe any special services that the student receives in school or through the school district *

Does the student have any allergies? Do they carry an EpiPen? *

I hereby authorize transport to the hospital for emergency treatment of my child in the event that I cannot be reached. I authorize the hospital to give emergency treatment to my child in the event that I cannot be reached. *

Is there any other information about your child we should be aware of? *

Use of images: *

I hereby give consent for my child’s pictures to be used in school newsletters, posters, newspapers, school website etc

I do not give consent for my child’s pictures to be used in school newsletters, posters, newspapers, school website etc.

Emergency Contact (if parent/guardian can’t be reached) Name, Phone Number and relationship to child. *

Student Public School Grade *

As of September 2022

Pre-K

Kindergarten

1st

2nd

3rd

4th

5th

6th

7th

Other:

Parent or Guardian: Sign *

Parent or Guardian: Date *

YYYY

Send me a copy of my responses.

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