For Academic Year 2016-2017




Student’s name:  _____________________________________________________________________


Student’s Hebrew name: _______________________________________________________


Home address________________________________________________________________


Home Phone:  __________________________________     Date of Birth:________________________


Secular School Grade as of September 2016: __________     Religious School Grade  _______________


Secular School Name:  ________________________________________________________________




Parent/Guardian 1: __________________________________________________________________            


Address, if different than student’s:_______________________________________________________


Daytime phone:  _____________________________           Evening phone:  _____________________


Cell phone:  ________________________________            Email address:  ______________________



Parent/Guardian 2:  ___________________________________________________________________         


Address, if different than student’s: _______________________________________________________


Daytime phone:  _____________________________           Evening phone:  _______________________


Cell phone:  _________________________________          Email address:  _______________________


Student lives with:  _____________________________________________________________________


Additional Wednesday Classes In Prayer, Torah and Hebrew: Please indicate here whether your child will be enrolled in this special 4:30 – 5:45 p.m. class for which there will be an additional charge of $ 100 for the whole year.







Student’s Name ______________________________________________________________


Emergency Contact 1 (other than parent / guardian):  _________________________        Phone: ________________


Emergency Contact 2 (other than parent / guardian):  __________________________       Phone: ________________


Doctor’s name: _________________________________________      Phone:  _____________________________


Health Insurer:  ___________________________   Policy #:  ___________________   Group #:__________________


Does your child take any medications, have any illness or chronic condition that school personnel needs to be aware of (i.e., asthma, dietary restrictions, allergies, ADD/ADHD, hearing, vision, speech)?  If yes, please list:


Congregation B’nai Israel cannot be responsible for administering any medications to any student. Please administer your child’s medications at home, before your child comes to school.   Please do not send medications with your child to school. 


In case of injury or illness while your child is at school, every effort will be made to contact the parent/guardian or emergency contact.  The following instructions will remain in force for the current academic year unless revoked in writing by the parent/guardian:


I give permission to the staff at Congregation B’nai Israel to administer first aid to my child when she/he is in attendance during Religious School or Religious School events.  In case of a medical emergency, I authorize the staff at Congregation B’nai Israel to obtain emergency medical and/or emergency surgical treatment for my child.



Parent/Guardian signature:  _______________________________________________________      Date:  __________






At Congregation B’nai Israel we strive to establish an environment in which all types of learners may thrive.  Information you provide about your child’s learning strengths and challenges will assist in our efforts to accommodate and provide for those needs. Any information you provide will be held in the strictest confidence and will be shared only as necessary to provide your child with a quality educational experience.


My child has an IEP ____________________________   Copy of IEP will be provided _______________


Other Learning or Physical Needs _________________________________________________________


Special accommodations required _________________________________________________________


If you indicate any special needs you will be contacted by the Director of Schools to discuss how best to support your child. If you prefer to contact Rabbi Schechter at 908-204-1412 x105








CBI’s Religious School is proud to publicize the accomplishments of our students in the local media, in synagogue publications, and on our website. While the intent of this practice is to be informative, we understand concerns about individual rights to privacy.  If you wish to have your child’s name and photograph excluded from public recognitions please sign below.



Parent/Guardian Name (Print)                                     Signature of Parent/Guardian                                      Date

Sat, 25 February 2017 29 Shevat 5777