Religious School Registration

Parent/Guardian 1

* First Name

* Last Name

* Street Address

* City

State

Zip Code

Home Phone

* Mobile Phone

Business Phone

* Email

Alternate Email

Parent/Guardian 2

First Name

Last Name

Street Address

City

State

Zip Code

Home Phone

Mobile Phone

Business Phone

Alternate Email

Child 1

* First Name

Middle Initial

* Last Name

Birthdate

Hebrew Name

* School

* Grade

Does your child have any learning issues that the school should be aware of?

Please explain:

Does your child have an IEP?

Please explain:

Does your child have any food, insect or environmental allergies?

Please list:

Are there circumstances or issues regarding your child we should be aware of?

Please explain:

Are you registering another child?

Child 2

First Name

Middle Initial

Last Name

Birthdate

Hebrew Name

School

Grade

Does your child have any learning issues that the school should be aware of?

Please explain:

Does your child have an IEP?

Please explain:

Does your child have any food, insect or environmental allergies?

Please list:

Are there circumstances or issues regarding your child we should be aware of?

Please explain:

Are you registering another child?

Child 3

First Name

Middle Initial

Last Name

Birthdate

Hebrew Name

School

Grade

Does your child have any learning issues that the school should be aware of?

Please explain:

Does your child have an IEP?

Please explain:

Does your child have any food, insect or environmental allergies?

Please list:

Are there circumstances or issues regarding your child we should be aware of?

Please explain:

Permissions

I hereby give permission for my child(ren) to be driven home by:

My child(ren) is/are allowed to walk home by themselves:

NoYes

I hereby give permission for my child(ren) to attend school field trips:

YesNo

I hereby authorize Temple Emanu-El to arrange emergency medical treatment for my child(ren) while at school:

YesNo

I hereby authorize Temple Emanu-El to photograph my child(ren) and use the images in print and electronically:

YesNo

Emergency Information

Physician's Name

Physician's Phone

Health Insurance Company

Policy Number

Emergency Contact 1

Phone

Emergency Contact 2

Phone

Click the "Submit" button below to complete your registration.

If you have any questions, contact Rachel Cohn at 401.331.1616 or rcohn@teprov.org.

Thu, December 1 2022 7 Kislev 5783