CONGREGATION B’NAI ISRAEL RELIGIOUS SCHOOL 2016-17
For Academic Year 2016-2017
Student’s name: _____________________________________________________________________
Student’s Hebrew name: _______________________________________________________
Home Phone: __________________________________ Date of Birth:________________________
Secular School Grade as of September 2016: __________ Religious School Grade _______________
Secular School Name: ________________________________________________________________
PARENT / GUARDIAN INFORMATION
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.
EMERGENCY AND MEDICAL INFORMATION
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
EXCLUSION FROM PUBLICITY
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