2023-2024 Religious School Registration - Form - Temple Israel of New Rochelle

* Is your family new to our community?

Please Select OneYesNo

* I understand that my child's registration in the Chavaya program is contingent upon our contribution towards Membership.

Please Select OneYes

Is your child new to our program?

YesNo

Section A: Family Contact Information

* First Name (Primary)

* Last Name (Primary)

* Relationship to Student(s) (Primary)

* Email (Primary)

* Phone (Primary)

* Cell Phone

* Street Address (Primary)

Street Address Line 2 (Primary)

* City (Primary)

* State (Primary)

* ZIP (Primary)

* Is there a secondary contact? If there is a secondary contact, all emails and mailings will go to both contacts. In case of urgent need, the primary contact will be notified first

Please Select OneNoYes, at the same address as the primary contactYes, but at a different address than the primary contact

First Name (Secondary)

Last Name (Secondary)

Relationship to Student(s) (Secondary)

Email (Secondary)

Phone (Secondary)

Street Address (Secondary)

Street Address Line 2 (Secondary)

City (Secondary)

State (Secondary)

ZIP (Secondary)

Section B: Emergency Contact Information

* Emergency Contact Name: Please list someone other than a parent

* Emergency Contact Phone

* Emergency Contact Relationship

Section C: Student Enrollment Information

How many Kindergarten - 12th grade children are being enrolled for the 2023-2024 year?

Please Select One1 Child2 Children3 Children

Student 1 Information

* Student 1 First Name

* Student 1 Last Name

Gender Child Associates With

MaleFemaleTransgenderNon-binary

* Student 1 Birthdate

Student 1 Hebrew Name

Student 1 Nickname (if applicable)

* Is your child becoming B'nei Mitzvah during the 2023-2024 school year?

Please Select OneYesNo

* Student 1 Secular School Name

Student 1 Phone (if applicable): Information will not be shared publicly. Students will not be contacted independently from parents.

Student 1 Email (if applicable): Information will not be shared publicly. Parents will be copied on all communication to students.

* Student 1 Special Learning Needs: Please include information if your child has an IEP or 504 in place in their secular school as this information may be helpful in addressing their specific needs. This information will be kept confidential by the Director of Education and will only be shared with the teaching team and Clergy as needed.

* Student 1 Allergies or Medications: Does your child have allergies or medications we need to know about?

Please Select OneNoYes

Student 1 Allergy/Medication Details: Please describe allergies and medications that pertain to Chavaya programmingwith dosage and timing.

Please list a maximum of three participants with whom your child would like to be in a group. We will do our best to factor these requests with other considerations such as group size, gender balance, and group dynamics.

Student 2 Information

Student 2 First Name

Student 2 Last Name

Gender Child Associates With

MaleFemaleTransgenderNon-binary

Student 2 Birthdate

Student 2 Hebrew Name

Student 2 Nickname (if applicable)

Is your child becoming B'nei Mitzvah during the 2023-2024 school year?

Please Select OneYesNo

Student 2 Secular School Name

Student 2 Phone (if applicable): Information will not be shared publicly. Students will not be contacted independently from parents.

Student 2 Email (if applicable): Information will not be shared publicly. Parents will be copied on all communication to students.

Student 2 Special Learning Needs: Please include information if your child has an IEP or 504 in place in their secular school as this information may be helpful in addressing their specific needs. This information will be kept confidential by the Director of Education and will only be shared with the teaching team and Clergy as needed.

Student 2 Allergies or Medications: Does your child have allergies or medications we need to know about?

NoYes

Student 2 Allergy/Medication Details: Please describe allergies and medications that pertain to Chavaya programming with dosage and timing.

Student 3 Information

Student 3 First Name

Student 3 Last Name

Gender Child Associates With

MaleFemaleTransgenderNon-binary

Student 3 Birthdate

Student 3 Hebrew Name

Student 3 Nickname (if applicable)

Is your child becoming B'nei Mitzvah during the 2023-2024 school year?

Please Select OneYesNo

Student 3 Secular School Name

Student 3 Email (if applicable): Information will not be shared publicly. Parents will be copied on all communication to students.

Student 3 Phone (if applicable): Information will not be shared publicly. Students will not be contacted independently from parents.

Student 3 Special Learning Needs: Please include information if your child has an IEP or 504 in place in their secular school as this information may be helpful in addressing their specific needs. This information will be kept confidential by the Director of Education and will only be shared with the teaching team and Clergy as needed.

Student 3 Allergies or Medications: Does your child have allergies or medications we need to know about?

NoYes

Student 3 Allergy/Medication Details: Please describe allergies and medications that pertain to Chavaya programming with dosage and timing.

Section D: Release Forms

By signing my name below, my child(ren) have permission to participate in the Religious School at Temple Israel of New Rochelle. I hereby authorize the Education Director, or person designated by the Education Director, to obtain emergency medical care for my child(ren) in the event such care is indicated. I give my permission for my child(ren) to receive emergency medical care by any nurse, doctor, paramedic or member of a medical staff of a hospital licensed by the State of New York. I understand that every effort will be made to notify a parent/guardian prior to treatment.

I certify that my child(ren) is(are) in good physical health. They have my permission to participate in all activities that are part of the regular religious school program.

* Medical Release: Enter your name below

By typing my name, I confirm I have read, understand and agree to the above.

Media Release

From time to time your child’s photo may be taken in our classrooms or special events. We use these photos in the synagogue newsletters, on our synagogue website as well as our Facebook groups and other publicity materials.

* Media Release

Please Select OneI grant permission for my child's image to be usedI do not grant permission for my child’s image to be used

Section E: Immunization Record and Community Brit

All registered children must submit up-to-date immunization records and the Chavaya Brit (behavior contract) in order to participate in programming.

Physician's Name

Physician's Phone Number

Name of Insurance Company

Insurance Company ID

Insurance Policy Number

Immunization Record

Please upload your child(ren)'s Immunization records here.