Beit Bina Religious School Enrollment 5783 - Form

Please note that this enrollment form allows for maximum of two children per family, if you are in need of enrolling for three children, you will need to submit a second form.

* Parent/Guardian (1) Name

Parent/Guardian (2) Name

* Parent/Guardian (1) Best Phone Number

Parent/Guardian (2) Best Phone Number

* Parent/Guardian (1) Email

Parent/Guardian (2) Email

Parent/Guardian (1) Street

Parent/Guardian (2) Street (If Different)

Parent/Guardian (1) City

Parent/Guardian (2) City (If Different)

Parent/Guardian (1) State

Parent/Guardian (2) State (If Different)

Parent/Guardian (1) Zip

Parent/Guardian (2) Zip (If Different)

Additional Parent/Guardian Custody Information

Emergency Contact Name

Emergency Contact Cell Phone

Student (1) First Name

Student (2) First Name

Student (1) Last Name

Student (2) Last Name

* Enrollment Grade - Student (1)

* Enrollment Grade - Student (2)

School track-Student1

SundaySessionHebrew-School_3rd-7th_onlySundaySession+Hebrew-School_3rd-7th_only

School track-Student2

SundaySessionHebrew-School_3rd-7th_onlySundaySession+Hebrew-School_3rd-7th_only

Student (1) Hebrew Name

Student (2) Hebrew Name

Student (1) Birthday

Student (2) Birthday

ALLERGY INFORMATION

Information for Student (1)

Information for Student (2)

Does Student (1) have any allergies?

Yes. My child has allergies.No. My child has no allergies.

Does Student (2) have any allergies?

Yes. My child has allergies.No. My child has no allergies.

List all food allergies student (1):

List all food allergies student (2):

List all other allergies student (1):

List all other allergies student (2):

Does student (1) have an EpiPen?

YesNo

All EpiPens at Temple Israel must have photo ID attached.

Does student (2) have an EpiPen?

YesNo

All EpiPens at Temple Israel must have photo ID attached.

If yes, student (1) EpiPen location:

Special carrier on his/her personIn his/her backpackIn the classroom with the teacherOther

If yes, student (2) EpiPen location:

Special carrier on his/her personIn his/her backpackIn the classroom with the teacherOther

If other, please explain - student (1).

If other, please explain - student (2).

SCHOOL INFORMATION

Does student (1) have any medical conditions or learning differences or take any medication that could affect their religious school experience?

YesNo

Does student (2) have any medical conditions or learning differences or take any medication that could affect their religious school experience?

YesNo

If yes, please provide details for student (1).

If yes, please provide details for student (2).

Is there anything else you would like to share about student (1)?

Is there anything else you would like to share about student (2)?

FAMILY PUBLICITY PERMISSION

Yes I give my permission.No I do not give my permission.

By clicking yes - you are agreeing that Student's photograph, name, art, written work, voice, or verbal statements may appear in Temple Israel of Alameda publicity or publications.

FAMILY MEDICAL EMERGENCY INFORMATION

Doctor's Name:

Doctor's Phone Number:

Insurance Company

Policy ID Number

Group Number

Publicity Permissions

YESNOI hereby give permission for my child(ren) to be taken off Temple grounds for the purpose of medical attention in the event that I cannot be contacted in an emergency. I authorize and designate the Rabbi or Religious School Director as my representative in the event of a medical emergency concerning my child.

TUITION AND FEES 

Kinder-2nd Grade:   $690.00
________________________________________________

3rd Grade-7th Grade:   $1,025.00
________________________________________________

Bar/Bat/B'nei Mitzvah Preparation:   $1,000.00
_________________________________________________

Teacher Gift Donation:  $18.00 per child 

* If you feel like giving more to Youth Education please feel free to go to our Giving Page on Website. *

Pay in Full Option - Please enroll my child in (child1):

K - 2nd Grade3rrd - 7th GradeB'nei Mitzvah Prep (Bar/Bat/B'nei)Teacher Gift Card Donation (for end of school year

Pay in Full Option - Please enroll my child in (child2):

K - 2nd Grade3rd - 7th GradeB'nei Mitzvah Prep (Bar/Bat/B'nei)Teacher Gift Card Donation (for end of school year)

Total

Upon Submission of form, you will have the option of breaking out your payments to monthly, quarterly, or semi-annually if you choose.