Registration Form

Child's Information

Child's Full Name*

Child's Hebrew Name*

Gender*

Male
Female

Date of Birth*

Address*

Street Address Address Line 2 City State ZIP Code

Phone*

Grade in school as of September:

Family Information

Father's Name*

First Last

Father's Email*

Mother's Name*

First Last

Mother's Email*

Is the student's father Jewish?*

Yes
No

Is the student's mother Jewish?*

Yes
No

Can someone in your home read Hebrew?*

Yes
No

Emergency Contact Information

In case of emergency, parents can be reached by phone at:

Mother - Home

Mother - Work

Mother - Cell

Father - Home

Father - Work

Father - Cell

If parents cannot be reached during an emergency, please list someone else locally to contact.

Emergency Contact Name*

First Last

Relationship to child*

Emergency Contact Phone*

In the event of an emergency, do you give us permission to call an ambulance?*

Yes
No

Additional Information

Please share the following information with us; this information will be kept confidential.

Does your child have any special needs in the classroom?

Please list any medical problems (i.e., allergies).

Release Information*

We do not release student information to other organizations.

Yes, I would like my child's information included in the class directory which is distributed to the families in my child's class, my child's teacher, room parent and school administration.
No, I do not give permission, and request that my child's information be kept confidential (held only by administration, teacher and room parent).

Photo Release*

The Religious School and Synagogue occasionally photograph adults and children during class or special activities for use in press releases in local Jewish or secular newspapers, or for use in the synagogue newsletter, brochure or website. These photos are often on a spur-of-the-moment basis, which makes it difficult to obtain immediate consent. Adult and parental consent is requested for you and/or your child(ren) to be photographed at Adath Israel or during any of their activities. Please know that children's names will not be used in conjunction with any pictures.

Yes, I give permission for me or my child to be photographed for use in the local paper, synagogue newsletter, brochure or website
No, I do not give permission

Parent's Signature*

Registration Form

Registration Form

Child's Information

Family Information

Emergency Contact Information

Additional Information

Education