Religious School Registration - Form

Parent/Guardian 1

* First Name

* Last Name

* Street Address

* City

State

Zip Code

Home Phone

* Mobile Phone

Business Phone

* Email

Alternate Email

Occupation

Employer

Parent/Guardian 2

First Name

Last Name

Street Address

City

State

Zip Code

Home Phone

Mobile Phone

Business Phone

Alternate Email

Occupation

Employer

Child 1

* First Name

Middle Initial

* Last Name

Hebrew Name

* Grade

Secular school

My child attended Camp in 2022, Camp Name

I am registering my child for

WeekdaySunday

Does your child have any learning issues that the school should be aware of?

Please explain:

Does your child have an IEP?

Please explain:

Does your child have any food, insect or environmental allergies?

Please list:

Are there circumstances or issues regarding your child we should be aware of?

Please explain:

Are you registering another child?

Child 2

First Name

Middle Initial

Last Name

Hebrew Name

* Grade

Secular school

My child attended Camp in 2021, Camp Name

I am registering my child for

WeekdaySunday

Does your child have any learning issues that the school should be aware of?

Please explain:

Does your child have an IEP?

Please explain:

Does your child have any food, insect or environmental allergies?

Please list:

Are there circumstances or issues regarding your child we should be aware of?

Please explain:

Are you registering another child?

Child 3

First Name

Middle Initial

Last Name

Hebrew Name

Date of Birth

* Grade

Secular school

My child attended Camp in 2021, Camp Name

I am registering my child for

WeekdaySunday

Does your child have any learning issues that the school should be aware of?

Please explain:

Does your child have an IEP?

Please explain:

Does your child have any food, insect or environmental allergies?

Please list:

Are there circumstances or issues regarding your child we should be aware of?

Please explain:

Permissions

I hereby give permission for my child(ren) to be picked up by:

My child(ren) is/are allowed to walk home by themselves:

NoYes

I hereby authorize The Village Temple to arrange emergency medical treatment for my child(ren) while at school:

YesNo

I understand that my/our child's likeness may be photographed or videotaped in an effort to inform the community of our unique RS programs and events. These images without names may be used in print and electronically:

YesNo

Emergency Information

Physician's Name

Physician's Phone

Health Insurance Company

Policy Number

Emergency Contact 1

Phone

Emergency Contact 2

Phone

Total tuition amount

Click the "Submit" button below to complete your registration.

If you have any questions, contact Alex Tansky at atansky@villagetemple.org