Sam S. Bloom Learning Center
STUDENT AND "MADRICHIM" ENROLLMENT FORM 2018-2019
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SCHOOL INFORMATION
School times: Sunday 9:15-12:15, Wednesday 4:15-6:15 (Grades 2-7 only)
Madrichim times: Sunday 9:15-12:15 (80% attendance required), Wednesdays optional, Grades 8-9
Last Sunday of the month: Lunch at 12:15 and catch-up class 12:45-1:45
Cost: K-1: free tuition, $180 Registration fee, Grades 2-7: $950, 3rd sibling discount, Madrichim: $250
Please see the Sam S. Bloom Learning Center Handbook 2.0 for more information
STUDENT INFORMATION
Student 1 Last Name, First Name *
Student 1 Hebrew/Jewish Name *
(If currently unknown, please state "unknown" to proceed. We will need the name for class.)
Student 1 Grade as of 8/01/2018 *
Student 1 Date of Birth *
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Student 1 School/School District
Student 2 Last Name, First Name
Student 2 Hebrew/Jewish Name
(If currently unknown, please state "unknown" to proceed. We will need the name for class.)
Student 2 Grade as of 8/01/2018
Student 2 Date of Birth
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Student 2 School/School District
Student 3 Last Name, First Name
Student 3 Hebrew/Jewish Name
(If currently unknown, please state "unknown" to proceed. We will need the name for class.)
Student 3 Grade as of 8/01/2018
Student 3 Date of Birth
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Student 3 School/School District
Are any students above incoming 6th or 7th graders who do not have a Bar/Bat-Mitzvah date yet? *
If so, please pick 3 possible Bar/Bat-Mitzvah dates for that student, and please contact the office to make an appointment with Rabbi to discuss which date works best. The dates should be on or after the child's 13th birthday. These are just potential dates as a starting point for discussion (so don't worry :-). The dates should be Saturdays.
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Possible Date 1
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Possible Date 2
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Possible Date 3
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PARENT INFORMATION
Parent 1 Last Name, First Name *
Parent 1 Address *
Parent 1 E-mail *
Parent 1 Cell Phone *
Parent 1 Home Phone *
Parent 1 Work Phone
Parent 2 Last Name, First Name
Parent 2 Address
Parent 2 E-mail
Parent 2 Cell Phone
Parent 2 Home Phone
Parent 2 Work Phone
Child(ren) Residing With:
check all that apply
Which parent should receive e-mail communications (mainly weekly newsletters and progress reports)
check all that apply
EMERGENCY INFORMATION
Emergency Contact Person (other than parent) *
Relationship to Student *
Emergency Cell Phone Number *
Emergency Home Phone Number *
Doctor Name
Doctor Phone
Health Insurance Company
Policy Number
HEALTH AND EDUCATIONAL INFORMATION
This information is being requested in order to better serve your child. This information will be kept confidential and shared only with necessary staff.  If you have more than one child enrolled, please indicate child 1, 2, or 3 per above.
Allergies
Visual or hearing
Does your child need to wear glasses in class? Is there a hearing impairment the teacher should be aware of?
Learning or other needs
Is there anything we should know about your child that will help us in the school, social, emotional, or learning. Our goal is to accommodate children with learning disabilities and behavior challenges. However, if a child needs an assistant to be in the classroom, the parents are responsible to provide for that assistant.  We are happy to discuss with you the possibilities of working with your child.
Is it okay to share your e-mail address in a school directory? *
ADDITIONAL INFORMATION AND PERMISSIONS
Authorized Pick-Up *
Who may pick up your child(ren) other than parent(s)? If no one other than parents may pick-up please type "none."
Medical Release *
Please check "I AGREE" below to agree to the following statement: “ In the event of an emergency, I authorize Ner Tamid Synagogue, its officers, agents and employees to administer first aid and/or transport my child(ren) to a physician or hospital, and I consent to emergency medical treatment for my child if a parent, guardian, or emergency contact cannot be reached.”
Required
LIABILITY WAIVER *
Please check "I AGREE" below to agree to the following statement: “I/we hereby release Ner Tamid Synagogue, its officers, agents, and employees from all liability for injuries, illness or property damage resulting from child’s participation in all department of education programs, including school and youth group activities , and agree not to make any claim or demand against them for any or all losses or damages to student’s person or property.”
Required
PERMISSION FOR PHOTOGRAPHS AND PUBLICITY *
Please check "I AGREE" below to allow us to put pictures of your child(ren) on our Ner Tamid Synagogue or Sam S Bloom Learning Center Facebook page or other publicity materials for educational and advertising purposes. The weekly newsletter is distributed to school families and select synagogue members only.
PLEASE "FRIEND" THE SAM S. BLOOM LEARNING CENTER FACEBOOK PAGE
Clear selection
PARENT 1 E-SIGNATURE *
please e-sign /FIRST NAME LAST NAME/. Your e-signature indicates that you have read and agree to all of the above.
PARENT 2 E-SIGNATURE
please e-sign /FIRST NAME LAST NAME/. Your e-signature indicates that you have read and agree to all of the above.
Today's date *
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