The Judy and Ronald Mack School of Religious Studies

Temple Beth Sholom

10700 Havenwood Lane, Las Vegas, NV 89135
Telephone: (702) 804-1333, ext. 114 Fax: (702) 243-8796
rsinfo@bethsholomlv.org www.bethsholomlv.org

Religious School 2009-2010

1. NAME Last
First Middle Hebrew

2. ADDRESS
Street City State Zip Code

3. HOME PHONE ( ) E-Mail (Student) E-Mail (Parent)

4. BIRTHDATE AGE _________ CIRCLE: MALE FEMALE

5. DAY SCHOOL DAY SCHOOL GRADE IN 09-10

6. RELIGIOUS SCHOOL GRADE (please circle) Gan (K) Alef Bet Gimmel Dalet Hay Vav Zayin
Midrasha

7. All RS Classes will meet on Sunday mornings. Students in Grades 3-7 must choose Monday or
Wednesday as their second day. Please check one: MONDAY WEDNESDAY

Please number your time preferences from 1 - 3. We will do our best to accommodate your
choices; time slots are limited to 5 students per grade, and preferences will be granted on a
first-come, first serve basis.
Time Slot: ___ 4:00-4:40 pm ___ 4:40-5:20 pm ___ 5:20-6:00 pm

8. NAME OF PARENT OR GUARDIAN Full Name

Daytime Phone # Cell Phone

9. NAME OF PARENT OR GUARDIAN

Full Name Daytime Phone
# Cell Phone #

10. PARENTS' MARITAL STATUS: MARRIED  DIVORCED  SINGLE 

WITH WHOM IS STUDENT LIVING?

11. IF PARENTS UNREACHABLE IN EMERGENCY, CALL ( ) Name / Relationship

to Student Telephone #

12. Is there any other information about your child that will help us meet his or her educational needs? If so,
please explain:

 Placement of children in a particular class is at the discretion of our Religious School Principal.
 It is understood and agreed that designees of the principal may photograph, film, videotape, audiotape or reproduce
written materials of the applicant for use in publications and publicity.
 It is understood and agreed that student contact information – including phone numbers and addresses – will be given
out in the form of a class list or in response to a classmate’s request to send an invitation for a celebration, such as
Bar/Bat Mitzvah.
 If and when the need for medical and/or surgical attention arises during the period of my child's official participation
in the Judy and Ronald Mack School of Religious Studies, I hereby grant permission for my child to be transported by
private vehicle or ambulance to an appropriate medical facility and to be treated by qualified medical authorities at
their discretion and that of the program leaders.
I am enclosing a non-refundable deposit in the amount of $200 payable to Temple Beth Sholom.
FINAL PAYMENT is due by December 1, 2009.

 Please bill my deposit to my credit card, # (Visa or

 M/C Only)
Exp. Date CCV#____________ Billing Zip Code: _____________

Signature of Parent Date

 Judy and Ronald Mack School of Religious Studies
Medical Release Form

________________________________
Student’s Name (PRINT)
ALLERGIES TO MEDICATION AND FOOD

Does your child suffer from any allergies? (e.g. bee sting, medications, etc.) Y N

If yes, please explain

NON-PRESCRIPTION MEDICATIONS
My child has my permission to self-administer the following non-prescription medications:

Medication Reason for Medication Dosage

PRESCRIPTION MEDICATIONS

My child has my permission to self-administer the following prescription medications:

\
Medication Reason for Medication Dosage

My child does NOT have my permission to self-administer prescription medications.

MEDICAL INSURANCE

Medical Insurance Company Phone

Policy Group Number
Insurance Company Address
Physician’s Name Phone
Physician’s Address

Signature of Parent/Guardian Date