Religious School Registration Form

Family Information
Name of Parent or Guardian #1*
First Last
Name of Parent or Guardian #2
First Last
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

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 #1
Student #1 Name*
Student #1 Grade*
Student #1 Birthdate*
Student #1 Hebrew Name
Student #1 Secular School Name*
Student #1 - Does your child have any learning or emotional issues?*
- Yes
- No
Student #1 - Please describe the diagnosis or issues*
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*
Student #2 Hebrew Name
Student #2 Secular School Name*
Student #2 - Does your child have any learning or emotional issues?*
- Yes
- No
Student #2 - Please describe the diagnosis or issues*
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*
Student #3 Secular School Name*
Student #3 Hebrew Name
Student #3 - Does your child have any learning or emotional issues?*
- Yes
- No
Student #3 - Please describe the diagnosis or issues*
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 and Kindergarten, 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, 2017 – August 31, 2018.
- I give permission for Kesher Israel to use photos/videos of my child
- I DO NOT give permission fopr Kesher Israel to use photos/videos of my child/children
Code of Conduct
Click Here to read the Kesher Israel Congregation Religious School Student 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
Tuition Payment Information
Which method will you use to pay Religious School Tuition?*
A 3% convenience fee will be added to all Credit Card and Paypal transactions
- Check to Kesher Israel Congregation
- Credit Card
- Paypal
- Direct Debit from Checking Account
3% Convenience fee for Credit Card and Paypal payments
Price: $0.00
10% discount for families with 3 or more students*
Price: $0.00
Total
$0.00
Billing Name*
First Last
Billing Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Billing Email*
Billing Phone*
Credit Card*

American Express
Discover
MasterCard
Visa
Card Number Expiration Date Security Code Cardholder Name
Direct Debit
Please fill out an ACH form for Direct Debit and send to joycebh@verizon.net or mail to Kesher Israel Congregation
Confirmation
Thank you for Registering for the 2017-18 Religious School Year

Family Information