2023-24 Registration – David Ari and Michael Eric Zukin Religious School | Kesher Israel Congregation

Family Information
Name of Parent or Guardian #1*
First Last
Name of Parent or Guardian #2
First Last
Has any of your contact information changed since last year?*
Please check all that apply
- Address
- Phone Number
- Email
- None of the above
Family Address*
Street Address Address Line 2 City State ZIP Code
Parent/Guardian #1 Email*
#1 Home Phone*
#1 Work Phone
#1 Cell Phone
Parent/Guardian #2 Email
#2 Home Phone
#2 Work Phone
#2 Cell Phone
Please send email correspondence to:*
- Parent/Guardian #1 Email
- Parent/Guardian #2 Email

Emergency Information
Emergency Contact #1*
First Last
#1 Relationship
#1 Phone*
Emergency Contact #2
First Last
#2 Relationship
#2 Phone
Family Physician*
Physician Phone*
Family Dentist
Dentist Phone

Insurance Information
Insurance Plan Information*
Medical Insurance*
Permission for Medical Treatment
I hereby give permission for the synagogue to secure all necessary treatment for the safety and health of my child. I understand that my child will be taken to the nearest hospital or appropriate medical facility as indicated by the emergency. I understand that in case of emergency, every effort will be made to reach me or my designated emergency contact.
Signature*

Student Information
How many children will attend the Religious School?*

Student #1
Student #1 Name*
Student #1 Grade*
Student #1 Birthdate*
MM slash DD slash YYYY
Student #1 Hebrew Name
Student #1 School District / Name of Secular School*
Student #1 - As all students are valued in our learning community, we ask you share with us if your child has an IEP or 504 health plan. Please check the box below that pertains to your child and we will be in contact with you. All information shared is confidential.*
- IEP
- 504
- My child does not have a standing IEP or 504 but I would like to discuss needs my child has as a learner.
- N/A
Student #1 - Does your child have any allergies, food allergies or medical concerns?*
Student #1 - If yes, please describe any medical concerns and list any allergies, food allergies and medication
Student #1 - Please list any FOOD RESTRICTIONS
Student #1 - I give permission for the following medications to be given to my child
- Tylenol
- Advil
- Motrin
- None of the above

Student #2 Name*
Student #2 Grade*
Student #2 Birthdate*
MM slash DD slash YYYY
Student #2 Hebrew Name
Student #2 School District / Name of Secular School*
Student #2 - As all students are valued in our learning community, we ask you share with us if your child has an IEP or 504 health plan. Please check the box below that pertains to your child and we will be in contact with you. All information shared is confidential.*
- IEP
- 504
- My child does not have a standing IEP or 504 but I would like to discuss needs my child has as a learner.
- N/A
Student #2 - Does your child have any allergies, food allergies or medical concerns?*
Student #2 If yes, please describe any medical concerns and list any allergies, food allergies and medication
Student #2 - Please list any FOOD RESTRICTIONS
Student #2 - I give permission for the following medications to be given to my child
- Tylenol
- Advil
- Motrin
- None of the above

Student #3 Name
Student #3 Grade*
Student #3 Birthdate*
MM slash DD slash YYYY
Student #3 Hebrew Name
Student #3 School District / Name of Secular School*
Student #3 - As all students are valued in our learning community, we ask you share with us if your child has an IEP or 504 health plan. Please check the box below that pertains to your child and we will be in contact with you. All information shared is confidential.*
- IEP
- 504
- My child does not have a standing IEP or 504 but I would like to discuss needs my child has as a learner.
- N/A
Student #3 - Does your child have any allergies or medical concerns?*
Student #3 If yes, please describe any medical concerns and list any allergies and medication
Student #3 - Please list any FOOD RESTRICTIONS
Student #3 - I give permission for the following medications to be given to my child*
- Tylenol
- Advil
- Motrin
- None of the above

Consent Form for Use of Photographs/Videos by Kesher Israel
Photography/Video Consent*
From time to time, Kesher Israel will publish images or video clips of activities to our KI website, KI Facebook Page, KI ELink, KI Link, and other electronic or printed material that will be accessible to the general public. These activities may be related to Kesher Israel Preschool, the Zukin Religious School, Youth Groups. No names will be used in captions. You may choose to grant permission for us to publish photographs or video clips of your child. David Ari and Michael Eric Zukin Religious School This permission form is valid from: September 1, 2023 – August 31, 2024.
- I give permission for Kesher Israel to use photos/videos of my child
- I DO NOT give permission for Kesher Israel to use photos/videos of my child/children
Code of Conduct
We have read and acknowledge the Kesher Israel Congregation Religious School Student Code of Conduct*
- Yes
Parent Signature*
Student #1 Signature*
Student #2 Signature
Student #3 Signature

Synagogue Dues Payment - Informational Only*
By which method have you / do you intend to pay your synagogue dues?
- Check
- Credit Card
- Direct Debit / ACH
Consider Making a Donation to the David Ari and Michael Eric Zukin Religious School at Kesher Israel Congregation
Kesher Israel has instituted our tuition free religious school program to minimize the financial burden on our young families. Our goal is to make it easier for families to participate in our community and provide their children with a quality Jewish education and the opportunity to build lifelong friendships with other Jewish children from Chester County. If you are able, please use the form below to donate to the David Ari and Michael Eric Zukin Religious school. While the grant received has allowed us to put this initiative in place, our religious school still operates in a deficit and any additional support that our families can provide will help guarantee that we can show the benefit of this program and hopefully secure its place to support our existing and future families for many years to come. Thank you for choosing to be a part of the David Ari and Michael Eric Zukin Religious School. Your support through enrollment, engagement, volunteerism, and donations will benefit all the children of our community providing an appreciation for their Jewish heritage, a love of Israel and a commitment to living a meaningful Jewish life.
Donation Amount
Total
$0.00
Which payment method will you use for your donation?*
- Check to Kesher Israel Congregation
- Paypal
- Venmo @kesher-israel
Donation Billing Information
Name
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Email
Confirmation
Thank you for Registering for the 2023-24 Religious School Year
Website
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2023-24 Registration – David Ari and Michael Eric Zukin Religious School

Religious School Enrollment Form 2023-24

Step 1 of 9

Family Information

Emergency Information

Insurance Information

Permission for Medical Treatment

Student Information

Student #1

Consent Form for Use of Photographs/Videos by Kesher Israel

Code of Conduct

Consider Making a Donation to the David Ari and Michael Eric Zukin Religious School at Kesher Israel Congregation

Donation Billing Information

Confirmation

The David Ari and Michael Eric Zukin Religious School