25-26 Youth Education Enrollment Form - Form

Thank you for registering for the 2025-2026/ 5786 year of youth education at Congregation Beth Sholom. We are looking forward to another wonderful year of learning and community building!

At Beth Sholom, your child/ren will experience engaging and dynamic learning 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.

Please choose from the following programs:

Kindergarten - 5th Grade
*COMBO PROGRAM* - Moadon Beth Sholom + Shabbat School - the most comprehensive and cost effective learning experience!
Moadon Beth Sholom - a unique Hebrew learning, Jewish after school program Thursday afternoons
Shabbat School - build relationships, immerse in tradition, tefillah, and joy Saturday mornings

6th - 7th Grade
B'nai Mitzvah program - prayer, practice, and purpose, Thursday evenings and Saturday mornings

8th - 12th Grade
Madrichim program - support the educators, develop leadership and childcare skills, earn income
Jews for Hot Cocoa - learn with community teens and diverse educators, be social and sip cocoa

Please help us plan and prepare properly by registering your child/ren by August 18, 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

* What pronouns do they use?

* 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 - PLEASE LIST ANY DIETARY NEEDS BELOW:

* STUDENT 1 - ALLERGIES, MEDICAL CONCERNS OR CURRENT MEDICATIONS

NoneAllergies (please list any allergies in the box below)Medical Concerns (please list any medical concerns in the box below)Current List of Medications (please list current medications being taken in the box below)

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

STUDENT 1 - YOUTH EDUCATION ENROLLMENT SELECTIONS

* Select a Grade Below

* COMBO: MOADON BETH SHOLOM + SHABBAT SCHOOL *

Grades K - 5 | Thursdays & Saturdays (Members Only)

MOADON BETH SHOLOM

Grades K - 5 | Thursdays 2:30 - 5:45 pm

SHABBAT SCHOOL

Grades K - 5 | Saturdays 10:00 am - 12:00 pm (Members only))

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

Grades 6 - 7 | Saturdays 10:00 am - 12:00 pm (9:30 am optional drop off) | Thursdays, In-Person | 5:00 - 7:00 pm (dinner included)B'nai Mitzvah Program Fees
*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

Jews for Hot Cocoa | Thursdays, Twice a Month | 7:00 - 8:30 pmMadrichim Program | Saturdays 9:00 am - 12:00 pm | Paid Opportunity

Would you like to enroll additional Children?YesNo

How many more are you enrolling?OneTwo

STUDENT 2 ENROLLMENT INFORMATION

* Full Name

Hebrew Name

Email

Phone

* Birthdate

* Primary School Name

* What pronouns do they use?

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

STUDENT 2 - PLEASE LIST ANY DIETARY NEEDS BELOW:

* STUDENT 2 - ALLERGIES, MEDICAL CONCERNS OR CURRENT MEDICATIONS
NoneAllergies (please list any allergies in the box below)Medical Concerns (please list any medical concerns in the box below)Current List of Medications (please list current medications being taken in the box below)

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

STUDENT 2 - YOUTH EDUCATION ENROLLMENT SELECTIONS

* Select a Grade Below

* COMBO: MOADON BETH SHOLOM + SHABBAT SCHOOL *
Grades K - 5 | Thursdays & Saturdays (Members Only)

MOADON BETH SHOLOM
Grades K - 5 | Thursdays 2:30 - 5:45 pm

SHABBAT SCHOOL
Grades K - 5 | Saturdays 10:00 am - 12:00 pm (Members only)

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

Grades 6 - 7 | Saturdays 10:00 am - 12:00 pm | Thursdays 5:00 - 7:00 pm (dinner included)B'nai Mitzvah Program Fees $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

Jews for Hot Cocoa | Thursdays, Twice a Month | 7:00 - 8:30 pmMadrichim Program | Saturdays 9:00 am - 12:00 pm | Paid Opportunity

STUDENT 3 ENROLLMENT INFORMATION

* Full Name

Hebrew Name

Email

Phone

* Birthdate

* Primary School Name

* What pronouns do they use?

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

STUDENT 3 - PLEASE LIST ANY DIETARY NEEDS BELOW:

* STUDENT 3 - ALLERGIES, MEDICAL CONCERNS, OR CURRENT MEDICATIONS

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

STUDENT 3 - YOUTH EDUCATION ENROLLMENT SELECTIONS

* Select a Grade Below

* COMBO: MOADON BETH SHOLOM + SHABBAT SCHOOL *

Grades K - 5 | Thursdays & Saturdays (Members only)

MOADON BETH SHOLOM

Grades K - 5 | Thursdays 2:30 - 5:45 pm

SHABBAT SCHOOL

Grades K - 5 | Saturdays 10:00 am - 12:00 pm (Members only)

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

POST B'NAI MITZVAH TEEN CLASSES & PROGRAMS

Jews for Hot Cocoa | Thursdays Twice a Month | 7:00 - 8:30 pm Madrichim Program | Saturdays 9:00 am - 12:00 pm | Paid Opportunity

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 & ROSTER 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

Please check this box if you do not want your contact information on a roster that will be shared with other members of the Youth Education community

CONSENT AND AUTHORIZATION

* I/We permit my/our child to attend all planned trips arranged by the CBS Youth Education team, 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