Sam S. Bloom Learning Center
STUDENT AND MADRICHIM ENROLLMENT FORM 2021-2022
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SCHOOL INFORMATION
School times:
SSBLC is in session Sundays and Wednesdays for grades K-7.
Sunday morning in person from 9:15 - 12:15.
Wednesdays on Zoom between 4:00pm and 6pm. Students will be assigned times based on learning needs.
Madrichim: Teens are an important part of the school community. The Madrichim program for 8th - 10th graders will be a combination of learning activities for teens and assisting in classrooms. Madrichim commit to work on Sunday mornings, and are invited to help on Wednesdays if they are able.

Cost:
K-1: free tuition, $360 non-refundable registration fee, due at registration.
Grades 2-7: $1250
Madrichim (grades 8-10): $360, includes USY membership.

Discounts: Enroll a sibling and receive 10% off the total tuition bill. Enroll a 3rd sibling and receive 20% off total tuition bill. Tuition includes Kadima/USY membership.

Fee calculations: Once registration is received, your total amount owed will be added to your bill. For additional financial consideration please use the annual Membership Dues form to communicate your request.
STUDENT INFORMATION
Student 1 Last Name, First Name (ex. Cohen, Barry) *
Student 1 Hebrew/Jewish Name *
(If currently unknown, please state "unknown" to proceed).
Student 1 Grade as of 9/01/2021 *
Student 1 Date of Birth *
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Student 1 School AND School District
Student 2 Last Name, First Name
Student 2 Hebrew/Jewish Name
(If currently unknown, please state "unknown" to proceed.)
Student 2 Grade as of 9/01/2021
Student 2 Date of Birth
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Student 2 School/School District
Student 3 Last Name, First Name
Student 3 Hebrew/Jewish Name
(If currently unknown, please state "unknown" to proceed.)
Student 3 Grade as of 9/01/2021
Student 3 Date of Birth
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Student 3 School/School District
PARENT INFORMATION
Parent 1 Last Name, First Name *
Parent 1 Address *
Parent 1 E-mail *
Parent 1 Cell Phone *
Parent 1 second contact number *
Parent 2 Last Name, First Name *
Parent 2 Address
Parent 2 E-mail
Parent 2 Cell Phone
Parent 2 second contact number
Child(ren) Residing With:
check all that apply
Which parent should receive e-mail communications (mainly weekly newsletters and progress reports)
check all that apply
EMERGENCY INFORMATION
Emergency Contact Person (other than parent) *
Relationship to Student *
Emergency Person's Cell Phone Number *
Emergency Person's second contact number *
Doctor Name
Doctor Phone
Health Insurance Company
Policy 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 which child by name. If there are no issues, please type "none" to proceed.
Allergies and medical notes *
Visual or hearing *
Does your child need to wear glasses in class? Is there a hearing impairment the teacher should be aware of?
Vaccinations *
Has your child received all vaccinations as required by the public school system?
Learning and other needs *
Is there anything we should know about your child that will help us in the school? This space is to help identify social, emotional, or learning needs. If your child has an IEP, 504 or other learning plan at their secular school it can help us tremendously to know some of the details of your child's learning differences. Please communicate so we can work together to provide support.
Is it okay to share your e-mail address in a school directory? *
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 authorize Ner Tamid Synagogue, its officers, agents and employees to administer first aid and/or transport my child(ren) to a physician or hospital, and I consent to emergency medical treatment for my child if a parent, guardian, or emergency contact cannot be reached.”
Required
LIABILITY WAIVER *
Please check "I AGREE" below to agree to the following statement: “I/we hereby release Ner Tamid Synagogue, its officers, agents, and employees from all liability for injuries, illness or property damage resulting from child’s participation in all department of education programs, including school and youth group activities , and agree not to make any claim or demand against them for any or all losses or damages to student’s person or property.”
Required
PERMISSION FOR PHOTOGRAPHS AND PUBLICITY *
Please check "I AGREE" below to allow us to put pictures of your child(ren) on our Ner Tamid Synagogue or Sam S Bloom 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.
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. Your signature also indicates that you agree to pay the non-refundable registration fee upon submission of this form. You may pay either by mailing a check, through your shulcloud account (www.nertamidsd.org/member/payment/php) or by contacting the office.
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. Your signature also indicates that you agree to pay the non-refundable registration fee upon submission of this form. You may pay either by mailing a check, through your shulcloud account (www.nertamidsd.org/member/payment/php) or by contacting the office.
Today's date *
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