Religious School Registration - 2022 - Event

Religious School Registration - 2022

Wednesday, June 1, 2022 • 2 Sivan 5782

6:00 PM - 7:00 PM

Register

Student Name

Date of Birth

Phone Number

Street Address

City:

Zip Code

Membership Status

Member of Neve ShalomNot a member of Neve ShalomMember of HPCT

Child's Hebrew Name

Parents Name - Name #1

Parent's Name - Name #2

Parent's Hebrew Name - Parent #1

Parent's Hebrew Name - Parent #2

Parent #1 - Relationship

Parent #2 - Relationship

Parent #1 - Cell Phone

Parent #2 - Cell Phone

Parent #1 - Work Phone

Parent #2 - Work Phone

Emergency Contact - Name:

Emergency Contact - Phone

Child's Doctor

Child's Doctor's Phone Number:

Allergies to the following medicine(s):

Allergies to the following food(s):

My child regularly takes the following medications:

Identified learning or special needs:

Does your child have an IEP?

YesNo

My child requires an Epi Pen which I will supply to the Religious School Director along with an allergy action plan.

YesNo

In case none of the above can be reached, or it is imperative to treat the child without delay, I hereby give permission to the School Administration to take my child to the nearest hospital for medical treatment

Parent Signature:

Books and Materials Fees

Tuition

Total due for this child

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