Union Temple Religious School Registration 2015-2016

Parent 1 Information
Name: ___________________________
Address: _________________________
City: _________ State: ____ Zip: ______
Home Phone: _____________________
Cell Phone: _________________ ______
Work Phone: ______________________
Occupation: _______________________
Email: _____________________ ______
Union Temple Member: Yes

Parent 2 Information
Name: ___________________________
Address: _________________________
City: _________ State: ____ Zip: ______
Home Phone: _____________________
Cell Phone: _______________________
Work Phone: ______________________
Occupation: _______________________
Email: ____________________________

No

Student Information
Student 1:
Name: _____________________________
Hebrew Name: ______________________
Gender: ____________________________
Birthdate: ___________________________
2015-2016 Grade: ____________________
Student 3:
Name: ______________________________
Hebrew: Name: _______________________
Gender: _____________________________
Birthdate: ____________________________
2015-2016 Grade: _____________________

Student 2:
Name: ______________________________
Hebrew Name: _______________________
Gender: _____________________________
Birthdate: ____________________________
2015-2016 Grade: _____________________

Union Temple Religious School Emergency Contact Information

Parent 1 Information
Name: __________________________
Address: ________________________
City: _________ State: ____ Zip: _____
Home Phone: ____________________
Cell Phone: _________________ _____
Work Phone: ________________ _____

Parent 2 Information
Name: __________________________
Address: ________________________
City: _________ State: ____ Zip: _____
Home Phone: ____________________
Cell Phone: ______________________
Work Phone: _____________________

Local Person to Contact in Case of Emergency (IF WE CANNOT REACH PARENTS)

Name: ____________________________
Relationship to Child: ___________
Phone Number: _____________________
Name: ____________________________
Phone Number: _____________________

Relationship to Child: ___________

Additional adults who have permission to pick up your child

__________________________________________________________________
My child has permission to walk home at the end of Religious School: _________
*If child needs to leave early a parent must come into the school to pick them up.

Name of Healthcare Professional: _________________________________________

Phone Number of Healthcare Professional: __________________________________
Medical Insurance Company and Policy #____________________________________
Allergies and Health Concerns:
Student 1:_________________________________________________
Student 2:________________________________________________
Student 3:________________________________________________
I/We the undersigned parent(s) of minor(s)_________________ do herby consent to any x-ray
examination, anesthetic, medical or surgical diagnosis or treatment and hospital service that may be
rendered to said minor under the general or special treatment service that may be rendered to said
minor under the general or special instructions of our physician or other physician called in any
emergency by the Director of Youth and Family Engagement, Rabbi, or responsible adult in the event
I/we cannot be reached, whether such diagnosis or treatment is rendered at the office of said
physician or at a licensed hospital. It is understood that conscientious effort will be made to notify me
or my spouse before such action is taken; but, if this is not possible, the expense of this service will
be accepted by me. It is understood that this consent is given in advance of any specific diagnosis or
treatment being required. This consent shall remain effective until revoked.
Signature__________________
Date______

Learning Style Information

All information provided will be held in confidence and shared only with the appropriate faculty and staff as necessary. It is
imperative that we know your child/ren strengths so that we can provide a high-quality educational experience that meets
your childs needs.

Student 1: _________________________________
Has your child ever been evaluated for social/ emotional concerns? ___________________
Does your child have an IEP? _________________
Vision Challenges- Wears Glasses_____ Wears Contacts___ Color Blind___ Visual Processing Disorder____
Reading challenges- Dyslexia_____ Reads below Grade Level______ Difficulty understanding or processing
written information______
Auditory challenges- Deafness____ Auditory Processing Disorder____ Difficulty understanding or processing
oral information______
Attention challenges- ADD/ADHD______ Easily distracted_____ Tendency to be overactive_____
Emotional challenges- Especially sensitive___ Difficulty interacting with peers____ Difficulty interacting with
adults_____
Student 2: _________________________________
Has your child ever been evaluated for social/ emotional concerns? ___________________
Does your child have an IEP? _________________
Vision Challenges- Wears Glasses_____ Wears Contacts___ Color Blind___ Visual Processing Disorder____
Reading challenges- Dyslexia_____ Reads below Grade Level______ Difficulty understanding or processing
written information______
Auditory challenges- Deafness____ Auditory Processing Disorder____ Difficulty understanding or processing
oral information______
Attention challenges- ADD/ADHD______ Easily distracted_____ Tendency to be overactive_____
Emotional challenges- Especially sensitive___ Difficulty interacting with peers____ Difficulty interacting with
adults_____
Student 3: _________________________________
Has your child ever been evaluated for social/ emotional concerns? ___________________
Does your child have an IEP? _________________
Vision Challenges- Wears Glasses_____ Wears Contacts___ Color Blind___ Visual Processing Disorder____
Reading challenges- Dyslexia_____ Reads Below Grade Level______ Difficulty understanding or processing
written information______
Auditory challenges- Deafness____ Auditory Processing Disorder____ Difficulty understanding or processing
oral Information______
Attention challenges- ADD/ADHD______ Easily distracted_____ Tendency to be overactive_____
Emotional challenges- Especially sensitive___ Difficulty interacting with peers____ Difficulty interacting with
adults_____
Please elaborate on any of the above. If there are other social or other concerns, please include it here and
attach any information necessary.

Union Temple of Brooklyn Religious School

2015-2016 Payment Agreement
Please complete and indicate the payment plan you will use.
Union Temple Preschool graduates get Free Kinder Kef Religious School Tuition
Grade
Member
Member Rate
Non Member
Non Member
Rate
Rate
Rate
Kef-3rd

Kinder
grades
4th Grade
5th-7th Grades *

(Early Bird)

(After August 14)

(Early Bird)

(After August 14)

$500

$525

$700

$725

$800
$800

$825
$825

$950
-

$975
-

*After grade 4, all students and parents must join the Temple

To get the Early Bird price registration must be turned in by August 14, 2015
Childs Name___________________________

Grade____

@ $ _________

Childs Name___________________________

Grade____

@ $_________

Childs Name ___________________________

Grade____

@ $ _________

Total School Fees for 2015-2016

= $ _________

To be paid as follows:
_____

Plan A

______ Plan B

100% with Registration

25 % with Registration
25 % by September 27, 2015
25 % by November 8, 2015
25 % by December 15, 2015

If you need further financial assistance please contact Mindy Sherry Director of Youth and Family
Engagement b,y email at educator@uniontemple.org or by telephone at (718)638-7600.
Parent Signature__________________________________________
Date: ___________

Parent Release Forms

Photo
On occasion photographs or videos of the students are taken at school. Please sign below to
give us consent to use these photographs in our bulletin or our website.
Student Name (Please Print) __________________
PHOTO/MEDIA RELEASE
I hereby grant permission for the Religious School to utilize artwork, photographs, or any
other visual representation of my son/daughter in connection with any Religious School
brochure, video, website, promotion, advertising, or other media.
I DO NOT grant permission for the Religious School to utilize artwork, photographs, or any
other visual representation of my son/daughter in connection with any Religious School
brochure, video, website, promotion, advertising, or other media.
____________________________________________
PARENT/LEGAL GUARDIAN
DATED: _________________

Religious School Permission Slip

I give my child ___________________________________________ permission to accompany
his/her Union Temple Religious School class on neighborhood walks and trips to the park, and
Botanical Garden for the 2015-2016 school years.
____________________
Print Parent Name

___________________
Parent Signature

_________
Date

Religious School Directory

Please check off which information you would like published in the Religious School
Directory. This directory will only be shared with Religious School Families and Union
Temple Staff.
___ Please use only the Family Names in the Directory
___Please put the following information:
Student Name
Parents name
Address
Home phone number
Parents cell phone number
Parents email address
Student Name_____________________
Parent Signature___________________

Date _____

Parent Volunteer Form

Jewish education is a partnership between the families and the synagogue. Both are vital components in a successful
program. Throughout the Religious School year we rely on parents for a variety of things, including helping in the
classrooms, at special events, and sharing your skills and talents.

I would like to be a ROOM PARENT.

A Room Parent keeps in contact with his/her childs teacher and assists the teacher with special projects and events. You
may help organize a special event or help find other parents to volunteer on particular days (such as latke making!).

I would like to be on the First Friday Family Shabbat Parent Committee. This group will help advertise
the First Family Shabbats, and create themes and decorations for the Shabbat dinners.

I have a SKILL/TALENT that I would be happy to share with the Religious School. For example: Have you
recently visited Israel and would be willing to talk to your childs class?
Do you play a musical instrument? Do you love to cook and would be happy to assist a teacher in a cooking project? Are
you an artist?
My skill/talent is:

I would be happy to help with SPECIAL

Fundraisers
Family Programming
High Holiday Programming

PROJECTS throughout the year. For example:

Name____________________________________

Yom Haatzmaut Celebration

Purim Celebration
Passover Celebration

Phone Number__________________________

Email Address_____________________________
My child__________________________________

will be in

grade.

My child__________________________________

will be in

grade.

My child__________________________________

will be in

grade.