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Family Information

* Family Name

* Parent 1 Full Name

Parent 2 Full Name

* Are you a current member of Congregation Beth El?

Yes

No

We are considering joining, please send us more information about membership.

* Home Phone Number

Mobile Number

* Parent 1 Name and Cell Phone Number

Parent 2 Name and Cell Phone Number

* Parent 1 Name and Email Address

Parent 2 Name and Email Address

* Family Mailing Address

* Payment Plan Options

* Emergency Contact 1 Name

* Relationship to Child(ren)

* Emergency Contact 1 Phone Number

* Emergency Contact 2 Name

* Relationship to Child(ren)

* Emergency Contact 2 Phone Number

Student Information

* Child 1's Full Name

* Child 1's Full Hebrew Name

Please provide us with your child's full Hebrew Name which should include parents names. (Example for a Girl: Sarah Bat Yakov v' Razel; Example for a Boy: Moshe Ben Yakov v' Razel).

* Child 1's Date of Birth

* Child 1's Gender

Male

Female

* Child 1's Grade- Fall 2017

* Public/Day School Child 1 Attends

* Child 1's Days of Attendance

Additional Information about Child 1 (Allergy, Medical, Educational Plans, etc.)

Please include any important information about your child (i.e. allergy information, important medical information, if your child has an I.E.P or 504 plan in public school). All information provided is strictly confidential and will only be shared with the BERS staff that will be working directly with your child.

Child 2's Full Name

Child 2's Full Hebrew Name

Please provide us with your child's full Hebrew Name which should include parents names. (Example for a Girl: Sarah Bat Yakov v' Razel; Example for a Boy: Moshe Ben Yakov v' Razel).

Child 2's Date of Birth

Child 2's Gender

Male

Female

Child 2's Grade- Fall 2017

Child 2's Days of Attendance

Public/Day School Child 2 Attends

Additional Information about Child 2

Please include any important information about your child (i.e. allergy information, important medical information, if your child has an I.E.P or 504 plan in public school). All information provided is strictly confidential and will only be shared with the BERS staff that will be working directly with your child.

Child 3's Full Name

Child 3's Full Hebrew Name

Please provide us with your child's full Hebrew Name which should include parents names. (Example for a Girl: Sarah Bat Yakov v' Razel; Example for a Boy: Moshe Ben Yakov v' Razel).

Child 3's Date of Birth

Child 3's Gender

Male

Female

Child 3's Grade- Fall 2017

Child 3's Days of Attendance

Public/Day School Child 3 Attends

Additional Information about Child 3

Please include any important information about your child (i.e. allergy information, important medical information, if your child has an I.E.P or 504 plan in public school). All information provided is strictly confidential and will only be shared with the BERS staff that will be working directly with your child.

Child 4's Full Name

Child 4's Full Hebrew Name

Please provide us with your child's full Hebrew Name which should include parents names. (Example for a Girl: Sarah Bat Yakov v' Razel; Example for a Boy: Moshe Ben Yakov v' Razel).

Child 4's Date of Birth

Child 4's Gender

Male

Female

Child 4's Grade- Fall 2017

Child 4's Days of Attendance

Public/Day School Child 4 Attends

Additional Information about Child 4

Please include any important information about your child (i.e. allergy information, important medical information, if your child has an I.E.P or 504 plan in public school). All information provided is strictly confidential and will only be shared with the BERS staff that will be working directly with your child.

Parental Permissions

* Photographing of Child(ren)

Yes, my child(ren) may be photographed for both internal and external use (class projects, marketing, social media posts to the BERS & Congregation Beth El Facebook pages, etc.).

Yes, my child(ren) may be photographed, but only for internal uses (class projects, etc.).

No, my child(ren) may NOT be photographed for any reason.

By signing electronically below, I give my permission to the Educational Director, Religious School Administrators, Rabbi, or person designated in charge to call an appropriate medical professional or to take my child(ren) to the hospital to receive appropriate emergency treatment in the case of an emergency and a parent/legal guardian cannot be reached.

* Parent/Guardian Signature

By signing electronically below, I authorize that the information provided in this registration form is correct and up-to-date. I am also authorizing this registration form to be processed.

* Parent/Guardian Signature

Payment Information

Account

Online Fee:

Religious School Registration

Family Information

Student Information

Parental Permissions

Recurring Payment

Account Details

Payment Information

Credit Card

Checking Account

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