- Form - Congregation Beth Sholom

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YOUTH EDUCATION REGISTRATION

Thank you for registering for the 2023-2024 / 5784 year of education at Congregation Beth Sholom. We are looking forward to another wonderful year of learning and community building!

Each Saturday morning at Shabbat School, your child/ren will experience engaging and dynamic opportunities that will enable them to make meaning and connection to their individual and communal Jewish identities. The innovative and multisensory Jewish Life and Learning LabPlaySpace will be our hub and the foundation for how we intend to provide a rich, profound and powerful curriculum.

Due to our community's survey responses and our desire to offer more opportunities for our youth to be and learn together, we are excited to introduce Moadon Beth Sholom - a unique Jewish after school program! Spend one or two afternoons a week on the Beth Sholom campus exploring, learning about and engaging with Judaism. Hebrew will be a part of the learning experience at Moadon Beth Sholom and the virtual option on Thursdays remains if that is your family's preference.

The Madrichim program continues for our post b'nai mitzvah students interested in supporting the educators, developing their leadership, childcare skills and earning some income. And Jews for Hot Cocoa powers on as the space and time for our community teens to learn together and shape their Jewish futures!

Please help us plan and prepare properly by registering your child/ren, this will allow us to create the best learning groups and most compelling experiences for all.

PARENT 1 INFORMATION

* First Name

* Last Name

* Cell Phone

* Email

* Home Address

* City

* State

* Zip Code

Send Mail to this Address

Is there another Parent to add?YesNo

Does Parent 2 live at the address above?YesNo

You selected multiple households, the child(ren) live with?Both ParentsParent 1Parent 2

PARENT 2 INFORMATION

* First Name

* Last Name

* Cell Phone

* Email

* Home Address

* City

* State

* Zip Code

Send Mail to this Address

STUDENT 1 ENROLLMENT INFORMATION

* Full Name

Hebrew Name

Email

Phone

* Birthdate

* Primary School Name

* STUDENT 1 - EDUCATIONAL INFORMATION
(check all that apply)

Has a 504 plan or an IEPAttends a Resource Room in schoolHas an Aide/Paraprofessional in schoolIs a Gifted/Accelerated LearnerNo Educational Information to provideOther (please add other educational information in the box below)

* STUDENT 1 - ALLERGIES AND/OR MEDICAL CONCERNS

NoneAllergies (please list any allergies in the box below)Medical Concerns (please list any medical concerns in the box below)Both, Allergies & Medical Concerns (please list any allergies and/or medical concerns in the box below)

STUDENT 1 - CURRENT LIST OF MEDICATIONS

IS THERE ANYTHING ELSE YOU WOULD LIKE TO SHARE ABOUT THIS CHILD?

STUDENT 1 - YOUTH EDUCATION ENROLLMENT SELECTIONS

* Select a Grade Below

SHABBAT SCHOOL

Grades K - 5 | Saturdays, In-Person | 10:00 am - 12:00 pm (9:30 am optional drop off) | $1,400

MOADON BETH SHOLOM CLASSES (OPTIONAL)

SMALL GROUP HEBREW CLASS (OPTIONAL)

Grades 2 - 5 | Thursdays, Virtual | 45 min sessions between 4:00 - 7:00 pm | $600

B'NAI MITZVAH KEVAH (ROUTINE) & KAVANAH (PURPOSE) PROGRAM

Grades 6 - 7 | Saturdays, In-Person | 10:00 am - 12:00 pm (9:30 am optional drop off) | $2,000
Grades 6 - 7 | Thursdays, In-Person | 5:00 - 7:00 pm (dinner included)B'nai Mitzvah Program Fees | $1,000*
*Selecting this box will not charge you. $500 deposit will be collected once you select a date, final $500 will be billed 3 months before the date to cover overhead costs.

POST B'NAI MITZVAH TEEN CLASSES & PROGRAMS

ADDITIONAL DONATION

The actual cost of the Youth Education Programs are well over the tuition fees listed above. To help support our programs, we encourage anyone who is able to make an additional, one-time contribution.

Please add a one-time donation of $180 to this child's tuitionPlease add a one-time donation of the amount entered below to this child's tuition.

Would you like to enroll additional Children?YesNo

How many more are you enrolling?OneTwoThree

STUDENT 2 ENROLLMENT INFORMATION

* Full Name

Hebrew Name

Email

Phone

* Birthdate

* Primary School Name

* STUDENT 2 - EDUCATIONAL INFORMATION
(check all that apply)

* STUDENT 2 - ALLERGIES AND/OR MEDICAL CONCERNS

STUDENT 2 - CURRENT LIST OF MEDICATIONS

IS THERE ANYTHING ELSE YOU WOULD LIKE TO SHARE ABOUT THIS CHILD?

STUDENT 2 - YOUTH EDUCATION ENROLLMENT SELECTIONS

* Select a Grade Below

SHABBAT SCHOOL

Grades K - 5 | Saturdays, In-Person | 10:00 am - 12:00 pm (9:30 am optional drop off) | $1,400

MOADON BETH SHOLOM CLASSES (OPTIONAL)

SMALL GROUP HEBREW CLASS (OPTIONAL)

Grades 2 - 5 | Thursdays, Virtual | 45 min sessions between 4:00 - 7:00 pm | $600

B'NAI MITZVAH KEVAH (ROUTINE) & KAVANAH (PURPOSE) PROGRAM

POST B'NAI MITZVAH TEEN CLASSES & PROGRAMS

Please add a one-time donation of $180 to this child's tuitionPlease add a one-time donation of the amount entered below to this child's tuition.

STUDENT 3 ENROLLMENT INFORMATION

* Full Name

Hebrew Name

Email

Phone

* Birthdate

* Primary School Name

* STUDENT 3 - EDUCATIONAL INFORMATION
(check all that apply)

* STUDENT 3 - ALLERGIES AND/OR MEDICAL CONCERNS

STUDENT 3 - CURRENT LIST OF MEDICATIONS

IS THERE ANYTHING ELSE YOU WOULD LIKE TO SHARE ABOUT THIS CHILD?

STUDENT 3 - YOUTH EDUCATION ENROLLMENT SELECTIONS

* Select a Grade Below

SHABBAT SCHOOL

Grades K - 5 | Saturdays, In-Person | 10:00 am - 12:00 pm (9:30 am optional drop off) | $1,400

MOADON BETH SHOLOM CLASSES (OPTIONAL)

SMALL GROUP HEBREW CLASS (OPTIONAL)

Grades 2 - 5 | Thursdays, Virtual | 45 min sessions between 4:00 - 7:00 pm | $600

B'NAI MITZVAH KEVAH (ROUTINE) & KAVANAH (PURPOSE) PROGRAM

POST B'NAI MITZVAH TEEN CLASSES & PROGRAMS

Please add a one-time donation of $180 to this child's tuitionPlease add a one-time donation of the amount entered below to this child's tuition.

STUDENT 4 ENROLLMENT INFORMATION

* Full Name

Hebrew Name

Email

Phone

* Birthdate

* Primary School Name

* STUDENT 4 - EDUCATIONAL INFORMATION
(check all that apply)

* STUDENT 4 - ALLERGIES AND/OR MEDICAL CONCERNS

STUDENT 4 - CURRENT LIST OF MEDICATIONS

IS THERE ANYTHING ELSE YOU WOULD LIKE TO SHARE ABOUT THIS CHILD?

STUDENT 4 - YOUTH EDUCATION ENROLLMENT SELECTIONS

* Select a Grade Below

SHABBAT SCHOOL

Grades K - 5 | Saturdays, In-Person | 10:00 am - 12:00 pm (9:30 am optional drop off) | $1,400

MOADON BETH SHOLOM CLASSES (OPTIONAL)

SMALL GROUP HEBREW CLASS (OPTIONAL)

Grades 2 - 5 | Thursdays, Virtual | 45 min sessions between 4:00 - 7:00 pm | $600

B'NAI MITZVAH KEVAH (ROUTINE) & KAVANAH (PURPOSE) PROGRAM

POST B'NAI MITZVAH TEEN CLASSES & PROGRAMS

Please add a one-time donation of $180 to this child's tuitionPlease add a one-time donation of the amount entered below to this child's tuition.

EMERGENCY CONTACT INFORMATION

Please provide contact information for two people OTHER THAN A PARENT/GUARDIAN that we will contact in an emergency if we are unable to reach the parent(s) listed above.

* Emergency Contact 1 - Name

* Emergency Contact 1 - Cell Phone

* Emergency Contact 1 - Relationship to Student(s)

* Emergency Contact 2 - Name

* Emergency Contact 2 - Cell Phone

* Emergency Contact 2 - Relationship to Student(s)

MEDICAL AUTHORIZATIONS

* In the event of any emergency affecting the health or welfare of our child(ren) during which I/we cannot be immediately contacted, I/we authorize Congregation Beth Sholom personnel to seek emergency medical care, and I/we agree to assume responsibility for the cost of this care.

* The Educator and Office Staff have my/our permission to dispense over-the-counter medications such as acetaminophen, ibuprofen, or antihistamines to each named child above.

* Explain your "other" selection for the Medication Authorization

NAME & PHOTOGRAPH USE PERMISSION

* I give permission for each above named child's name and/or picture be included in congregational brochures, newsletters, website, and other promotional materials.

* Explain your "other" selection for the Name & Photograph Use Permission

CONSENT AND AUTHORIZATION

* I/We permit my/our child to attend all planned trips arranged by CBS Shabbat School, and release CBS, its officers, agents, and employees from any and all liability arising out of my child’s participation in such activity.

* I/We agree to notify the office in writing of any changes to the information listed on this form.

* I/We understand that payment for programs must be paid prior to the first class unless special arrangements have been made.

By typing your full name as your electronic signature, you attest that all information provided is accurate and agree to the permissions, consent and authorization outlined above.

* Signature

* Date

TOTAL TUITION & ADDITIONAL DONATIONS OWED

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Thu, May 9 2024 1 Iyyar 5784