Online Registration Form

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2016 – 2017 Religious School Registration

IMPORTANT: Please complete separate forms for each child

Your Name

Your email

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Students Last Name, First, Name, Middle (required)

Hebrew Name

Birth Date

Gender
 Male Female

NEW student to University Synagogue
 Yes No

Name of Secular School and City

Grade Level




CONTACT INFORMATION

Parent/Guardian

Jewish
 Yes No

Email

Home Phone

Cell Phone

Work Phone

Address (Street, City, Zip)

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Parent/Guardian

Jewish
 Yes No

Email

Home Phone

Cell Phone

Work Phone

Address (Street, City, Zip)




STUDENT MEDICAL

Does your child have any allergies or conditions that may require immediate or emergency care?

 Yes No

If "yes", please list and describe treatment :

Does your child have any medical conditions or take any medication(s)?

 Yes No

If "yes", please list and describe in the space below :

Student's Physician

Physician Phone

Physician Address

Student's Dentist

Dentist Phone

Dentist Address




EMERGENCY CONTACTS

Name

Relationship

Home Phone

Cell/Work Phone

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Name

Relationship

Home Phone

Cell/Work Phone




MEDICAL INSURANCE

Insurance Company Name

ID Number

Policy Number

Name Of Policy Holder




MEDICAL RELEASE AUTHORIZATION

In case of an accident or serious illness, I request that University Synagogue contact me immediately. If the school is unable to reach me, I hereby authorize the Religious School, or its authorized agent, to secure proper treatment for my child.

 Yes No

Typing in your name below will act as your electronic signature:




HELP US MEET YOUR CHILD'S NEEDS

In an effort to provide the best educational experience for your child, please provide any information pertaining to social, physical or emotional issues that may be a factor in the classroom. Please include strengths, talents and interests as well as challenges.

Parents who would like to participate in their child’s Jewish education by helping to plan holiday, family Shabbat programs and special activities in the Religious School.

 Yes, I would like to participate as a room parent Not at this time

Grade

Room Parent's Names




WEEKLY RELIGIOUS SCHOOL UPDATE EMAILS

In an effort to preserve our environment, the University Synagogue Religious School is doing its part by joining global efforts and going “green.” Most school information will be sent via an E-Flyer E-mail on a weekly basis. Please provide current e-mail address(s) to which you would like this information delivered, separated by commas:





RELIGIOUS SCHOOL DIRECTORY INFORMATION RELEASE FORM
In an effort to provide communication with your child’s teacher(s), assist room parents with coordinating and announcing school events as well as offer information for those interested in carpooling, we ask that parents provide the following information for the Religious School Directory.

This information will only be used for Religious School purposes.

I hereby give University Synagogue Religious School permission to submit the information provided in the 2016 - 2017 Religious School Directory.
 Yes No

Typing in your name below will act as your electronic signature:

Name

Email Address

Email Address

Home Phone

Cell Phone




PARENTAL CONSENT FOR STUDENT PHOTO RELEASE

During the school year special events and class activities at the US Religious School are illustrated in the local newspapers and magazines. We also use student photos in our school curriculum when communicating to other students across the globe in our grade level pen pals program.

The US Religious School requires parental permission in order to use photos that include your child with any school or classroom publicity.

Do you give University Synagogue Religious School permission to use photos of class or activity/special events that include your child for publication or curriculum purposes during the 2016 - 2017 school year?
 Yes No

Typing in your name below will act as your electronic signature:





PREVIOUS RELIGIOUS EDUCATION SETTINGS

You have my permission to contact any previous Religious School settings where our child has been enrolled. Any such information provided to the Religious School is kept strictly confidential and is used solely for the purpose of determining the best placement and setting for the child.
 Yes No

Typing in your name below will act as your electronic signature:

Name Of Previous Facility

Contact Person

Phone Number

Email

Dates Attended





PROFESSIONAL SERVICE PROVIDERS
You have my permission to contact current or previous professional service providers for our child (for example, speech therapist, physician, physical therapist). Any such information provided to the Religious School is kept strictly confidential and is used solely for the purpose of determining how best to serve the child’s needs while the child is enrolled and attends the Religious School. Parent(s) will be notified prior to contact.

 Yes No

Typing in your name below will act as your electronic signature:

Name Of Service Provider

Contact Person

Phone Number

Email

Dates Attended





UNIVERSITY SYNAGOGUE RELIGIOUS SCHOOL WAIVER, RELEASE AND MEDICAL AUTHORIZATION

I hereby give permission for my child to participate in events located at University Synagogue Irvine or off–site activities through the Synagogue, during the 2016-2017 school year.

I, the undersigned parent/guardian/legal representative hereby release and discharge University Synagogue, its officers, employees, agents and servants (herein collectively “University Synagogue”) from any and all liability arising out of or in connection with the above event. Liability means all claims, demands, losses, causes of action, suits, damages, or judgments of any and every kind that I and my child, our heirs, executors, administrators or assignees may have against University Synagogue because of any death, personal injury or illness, or because of any loss or damage, including loss to property that occurs during the above nature walk activity and that results from any cause other than the direct negligence of University Synagogue. This release applies to any liability my child or I may have a right to claim personally or by and through any other person.

In the event of any emergency, I hereby consent to whatever anesthetic, medical, dental or surgical diagnosis or treatment, radiologic study and hospital care from a licensed physician and/or surgeon as deemed necessary for the safety and welfare of my child, consistent with any prior authorizations and medical releases I previously have provided to University Synagogue. I understand that the resulting expenses will be the responsibility of the parent(s) or participant.

Health Insurance Company

Policy Number

Parent/Guardian Name

Phone Number

Typing in your name below will act as your electronic signature:

If your child has special health or pharmaceutical needs or allergies to medication or if there is someone other than the parent who should be contacted in an emergency, please list: