2019-20 Registration Form for the Rabbi Jacob H. Epstein School of Jewish Studies
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The Epstein School does not discriminate on the basis of race, color, gender, age, disability, national origin, or any other class of individuals protected by state and federal law, in any aspect of access to admissions, employment, financial aid, treatment of students in programs and activities, and other school administered programs.
FIRST STUDENT'S INFORMATION
Student's First Name *
Your answer
Student’s Middle Name
Your answer
Student's Last Name *
Your answer
Birthdate *
MM
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DD
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YYYY
Student’s school *
Your answer
Grade *
Does the student have allergies or a medical condition that the Epstein School should be aware of? *
If yes, please include information to help us keep your student safe and best meet their needs
Your answer
Would you like your student to receive educational accomodations while they are attending Epstein? (If yes, you will be contacted by the Director.)
The Epstein School would like to text your student occasional 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 Middle Name
Your answer
Student's Last Name (if different from your first student's)
Your answer
Birthdate
MM
/
DD
/
YYYY
Student’s school
Your answer
Grade
Does the student have allergies or a medical condition that the Epstein School should be aware of?
If yes, please include information to help us keep your student safe and best meet their needs.
Your answer
Would you like your student to receive educational accomodations while they are attending Epstein? (If yes, you will be contacted by the Director.)
The Epstein School would like to text your student occasional 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 Middle Name
Your answer
Student's Last Name (if different from the first student's)
Your answer
Birthdate
MM
/
DD
/
YYYY
Student’s school
Your answer
Grade
Does the student have allergies or a medical condition that the Epstein School should be aware of?
If yes, please include information to help us keep your student safe and best meet their needs.
Your answer
Would you like your student to receive educational accomodations while they are attending Epstein? (If yes, you will be contacted by the Director.)
The Epstein School would like to text your student occasional 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
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
PARENT/GUARDIAN VOLUNTEER OPPORTUNITIES
I would like to assist the Epstein Board of Directors in fundraising or other initiatives for the benefit of the Epstein School.
I'd like to volunteer in another capacity:
Your answer
I'd like to sponsor snack during break for $18 per night.
I'd like to sponsor an Epstein dinner or special event
I would like to add the following amount in addition to tuition as a tax deductible contribution.
Your answer
PARENT'S/GUARDIAN'S RESPONSIBILITIES AND SIGNATURE
You (the parent/guardian) will need to sign your name in the next few questions. Please read the following:
Yes, I confirm that I am a parent/legal guardian of the student(s) registered above for the Epstein School. Sign here: *
Your answer
SHALSHELET is an optional program funded by the Jewish Federation of CNY that provides subsidies to Epstein students who volunteer/work in our community's religious schools and/or the Syracuse Community Hebrew School.
NEW FOR 2019-2020: Yes, as the parent/guardian of the student(s) registered above, I understand the POLICY on ELIGIBILITY for SHALSHELET STIPEND: In order to receive a Shalshelet stipend, 1) the student must be registered and attend at least 60% of school sessions, and 2) tuition payments must be current or a completed scholarship form turned in. The full policy can be viewed (epsteincny.org/policy-on-shalshelet-subsidies1.html). Sign here: *
Your answer
NEW for 2019-2020: Yes, as the parent/guardian of the student(s) registered above, I understand the POLICY on TUITION PAYMENT: By October 15th, parents must either pay the full tuition, make payment arrangements and/or submit a written request for scholarship. If payment arrangements or scholarship requests are not submitted by November 15th, the student's account will be considered delinquent and the family will be contacted. If the tuition account remains delinquent as of January 1, the matter shall be brought before the Epstein school Board of Directors for further acton. The full Policy can be viewed (epsteincny.org/policy-on-tuition.html). Sign here: *
Your answer
I need a Payment Plan Form.
I need a Tuition Assistance Form.
I hereby give permission for the Rabbi Jacob H. Epstein School of Jewish Studies, Inc. to use photographs of my child/children for Epstein publicity in the Jewish Observer, Epstein's web site and Facebook page, in other media, and for marketing or fundraising purposes. *
I, a parent/guardian of the student(s) mentioned above, understand that my electronic signature and electronic submission of this registration form is the legal equivalent of having placed my handwritten signature on the registration form for the Epstein School. I understand and agree that by electronically signing and submitting the registration form in this fashion I am affirming to the truth of the information contained in the form. *
Required
Signature *
Your answer
Date *
MM
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DD
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YYYY
Submit
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