Religious School Registration


Rabbi Albert I. Gordon Religious School
Registration for Gan (K) through Makor (6/7)
2018-2019/5779

Parent Information

Parent 1
Last Name
First Name
MI
Street Address
City
State
Zip
Home Phone
Cell Phone
Work Phone
Select Preferred Phone
Email
Religious Background
Are you currently a Temple Emanuel Member?
YesNo
If not, are you a member of another synagogue?
ADD ANOTHER PARENT.
Yes
Parent 2
Last Name
First Name
MI
Street Address (if different from Parent 1)
City
State
Zip
Home Phone
Cell Phone
Work Phone
Select Preferred Phone
Email
Religious Background
Add other caretakers (e.g. nanny, babysitter, grandparent)
Yes
Other Caretakers
Name
Phone
Name
Phone
Name
Phone
Name
Phone

Student Information

Student 1
Last Name
First Name
Middle Name
Street Address (if different from Parent 1)
City
State
Zip
Gender
Date of Birth
Age (as of 9/2018)
Hebrew Name
Elementary/Middle School
Grade (as of 9/2018)

Enroll my child in the Tuesday Enrichment Program (2nd - 5th Graders, 4-6 pm at no additional charge)
YesNoPlease send me more information

If student's mother is not Jewish or if student is adopted, has student been converted?
YesNoN/A

Where?
Date
Previous Jewish Education: Has the student attended another synagogue or day school?
YesNo

If so, where?
Attended or will attend Jewish Day Camp?
YesNo
Camp
Attended or will attend Jewish Overnight Camp?
YesNo
Camp
Does your child have allergies or take medications on a regular basis?
YesNo
Allergy and Medication Information
My child is allergic to:
Allergy 1:
Type of Reaction:
Treatment:

Allergy 2:
Type of Reaction:
Treatment:

Allergy 3:
Type of Reaction:
Treatment:
I will provide an Epi-pen to the Religious School
YesNo
My child carries an Epi-pen in his/her backpack
YesNo
Please list regular medications child takes:
Would you like to provide helpful Learning Support Information for your child?
YesNo
Learning Support Information
If applicable, please help us support your child’s Jewish learning by completing this form.

Does your child have any emotional and/or familial issues of which we should be aware?

YesNo
If yes, please describe, and share any support plans in place:
Does your child have any learning, attention or behavioral issues of which we should be aware?
YesNo
If yes, please describe, and share any support plans in place:
Does your child have an IEP or 504 Plan?
YesNo
If yes, please submit a current copy to the Religious School.

Does your child receive individual support services in the classroom at secular school?

YesNo
If yes, please describe.
I give permission for the Religious School Director to communicate with my child’s public school teacher to share strategies for supporting my child’s learning.
YesNo
Would you like to provide input for your child's Class Placement?
YesNo
Class Placement Information
We believe that appropriate class placement is very important, and the education team puts much time and thought into assigning students to classes with the goal of creating an optimal learning environment for each child. Our objective is for every student to be successful in a supportive and challenging educational setting.

A team consisting of the school director, the current grade teachers, and the incoming grade teachers carefully consider the following factors in making classroom assignments:
• Class size and gender balance
• Academic strengths and learning styles
• Peer relationships
• Individual learning needs

Parents may provide input regarding classroom placement that includes the child’s learning style and a brief list of peers who would enhance the child’s learning experience. This information will be considered along with the above criteria. Final decision on student class placement will be made by the school director.
ADD ANOTHER STUDENT.
Yes
Student 2
Last Name
First Name
Middle Name
Street Address (if different from Parent 1)
City
State
Zip
Gender
Date of Birth
Age (as of 9/2018)
Hebrew Name
Elementary/Middle School
Grade (as of 9/2018)

Enroll my child in the Tuesday Enrichment Program (2nd - 5th Graders, 4-6 pm at no additional charge)
YesNoPlease send me more information

If student's mother is not Jewish or if student is adopted, has student been converted?
YesNoN/A

Where?
Date
Previous Jewish Education: Has the student attended another synagogue or day school?
YesNo

If so, where?
Attended or will attend Jewish Day Camp?
YesNo
Camp
Attended or will attend Jewish Overnight Camp?
YesNo
Camp
Does your child have allergies or take medications on a regular basis?
YesNo
Allergy and Medication Information
My child is allergic to:
Allergy 1:
Type of Reaction:
Treatment:

Allergy 2:
Type of Reaction:
Treatment:

Allergy 3:
Type of Reaction:
Treatment:
I will provide an Epi-pen to the Religious School
YesNo
My child carries an Epi-pen in his/her backpack
YesNo
Please list regular medications child takes:
Would you like to provide helpful Learning Support Information for your child?
YesNo
Learning Support Information
If applicable, please help us support your child’s Jewish learning by completing this form.

Does your child have any emotional and/or familial issues of which we should be aware?

YesNo
If yes, please describe, and share any support plans in place:
Does your child have any learning, attention or behavioral issues of which we should be aware?
YesNo
If yes, please describe, and share any support plans in place:
Does your child have an IEP or 504 Plan?
YesNo
If yes, please submit a current copy to the Religious School.

Does your child receive individual support services in the classroom at secular school?

YesNo
If yes, please describe.
I give permission for the Religious School Director to communicate with my child’s public school teacher to share strategies for supporting my child’s learning.
YesNo
Would you like to provide input for your child's Class Placement?
YesNo
Class Placement Information
We believe that appropriate class placement is very important, and the education team puts much time and thought into assigning students to classes with the goal of creating an optimal learning environment for each child. Our objective is for every student to be successful in a supportive and challenging educational setting.

A team consisting of the school director, the current grade teachers, and the incoming grade teachers carefully consider the following factors in making classroom assignments:
• Class size and gender balance
• Academic strengths and learning styles
• Peer relationships
• Individual learning needs

Parents may provide input regarding classroom placement that includes the child’s learning style and a brief list of peers who would enhance the child’s learning experience. This information will be considered along with the above criteria. Final decision on student class placement will be made by the school director.
ADD ANOTHER STUDENT.
Yes
Student 3
Last Name
First Name
Middle Name
Street Address (if different from Parent 1)
City
State
Zip
Gender
Date of Birth
Age (as of 9/2018)
Hebrew Name
Elementary/Middle School
Grade (as of 9/2018)

Enroll my child in the Tuesday Enrichment Program (2nd - 5th Graders, 4-6 pm at no additional charge)
YesNoPlease send me more information

If student's mother is not Jewish or if student is adopted, has student been converted?
YesNoN/A

Where?
Date
Previous Jewish Education: Has the student attended another synagogue or day school?
YesNo

If so, where?
Attended or will attend Jewish Day Camp?
YesNo
Camp
Attended or will attend Jewish Overnight Camp?
YesNo
Camp
Does your child have allergies or take medications on a regular basis?
YesNo
Allergy and Medication Information
My child is allergic to:
Allergy 1:
Type of Reaction:
Treatment:

Allergy 2:
Type of Reaction:
Treatment:

Allergy 3:
Type of Reaction:
Treatment:
I will provide an Epi-pen to the Religious School
YesNo
My child carries an Epi-pen in his/her backpack
YesNo
Please list regular medications child takes:
Would you like to provide helpful Learning Support Information for your child?
YesNo
Learning Support Information
If applicable, please help us support your child’s Jewish learning by completing this form.

Does your child have any emotional and/or familial issues of which we should be aware?

YesNo
If yes, please describe, and share any support plans in place:
Does your child have any learning, attention or behavioral issues of which we should be aware?
YesNo
If yes, please describe, and share any support plans in place:
Does your child have an IEP or 504 Plan?
YesNo
If yes, please submit a current copy to the Religious School.

Does your child receive individual support services in the classroom at secular school?

YesNo
If yes, please describe.
I give permission for the Religious School Director to communicate with my child’s public school teacher to share strategies for supporting my child’s learning.
YesNo
Would you like to provide input for your child's Class Placement?
YesNo
Class Placement Information
We believe that appropriate class placement is very important, and the education team puts much time and thought into assigning students to classes with the goal of creating an optimal learning environment for each child. Our objective is for every student to be successful in a supportive and challenging educational setting.

A team consisting of the school director, the current grade teachers, and the incoming grade teachers carefully consider the following factors in making classroom assignments:
• Class size and gender balance
• Academic strengths and learning styles
• Peer relationships
• Individual learning needs

Parents may provide input regarding classroom placement that includes the child’s learning style and a brief list of peers who would enhance the child’s learning experience. This information will be considered along with the above criteria. Final decision on student class placement will be made by the school director.
ADD ANOTHER STUDENT.
Yes
Student 4
Last Name
First Name
Middle Name
Street Address (if different from Parent 1)
City
State
Zip
Gender
Date of Birth
Age (as of 9/2018)
Hebrew Name
Elementary/Middle School
Grade (as of 9/2018)

Enroll my child in the Tuesday Enrichment Program (2nd - 5th Graders, 4-6 pm at no additional charge)
YesNoPlease send me more information

If student's mother is not Jewish or if student is adopted, has student been converted?
YesNoN/A

Where?
Date
Previous Jewish Education: Has the student attended another synagogue or day school?
YesNo

If so, where?
Attended or will attend Jewish Day Camp?
YesNo
Camp
Attended or will attend Jewish Overnight Camp?
YesNo
Camp
Does your child have allergies or take medications on a regular basis?
YesNo
Allergy and Medication Information
My child is allergic to:
Allergy 1:
Type of Reaction:
Treatment:

Allergy 2:
Type of Reaction:
Treatment:

Allergy 3:
Type of Reaction:
Treatment:
I will provide an Epi-pen to the Religious School
YesNo
My child carries an Epi-pen in his/her backpack
YesNo
Please list regular medications child takes:
Would you like to provide helpful Learning Support Information for your child?
YesNo
Learning Support Information
If applicable, please help us support your child’s Jewish learning by completing this form.

Does your child have any emotional and/or familial issues of which we should be aware?

YesNo
If yes, please describe, and share any support plans in place:
Does your child have any learning, attention or behavioral issues of which we should be aware?
YesNo
If yes, please describe, and share any support plans in place:
Does your child have an IEP or 504 Plan?
YesNo
If yes, please submit a current copy to the Religious School.

Does your child receive individual support services in the classroom at secular school?

YesNo
If yes, please describe.
I give permission for the Religious School Director to communicate with my child’s public school teacher to share strategies for supporting my child’s learning.
YesNo
Would you like to provide input for your child's Class Placement?
YesNo
Class Placement Information
We believe that appropriate class placement is very important, and the education team puts much time and thought into assigning students to classes with the goal of creating an optimal learning environment for each child. Our objective is for every student to be successful in a supportive and challenging educational setting.

A team consisting of the school director, the current grade teachers, and the incoming grade teachers carefully consider the following factors in making classroom assignments:
• Class size and gender balance
• Academic strengths and learning styles
• Peer relationships
• Individual learning needs

Parents may provide input regarding classroom placement that includes the child’s learning style and a brief list of peers who would enhance the child’s learning experience. This information will be considered along with the above criteria. Final decision on student class placement will be made by the school director.
Add other children (not listed as students on this form)
Yes
Other Children
Name
Grade
Age
Name
Grade
Age
Name
Grade
Age
Name
Grade
Age

Emergency Information

If possible, I prefer that my child/children be taken to the following hospital:
If possible, please contact the following physician:
Phone
Health Insurance Provider/Policy #:
Emergency Contact(s) (other than parents)
Name
Phone
Relationship (to children)
Name
Phone
Relationship (to children)

Parental Authorizations and Confirmations

YesNo
IMMUNIZATIONS: I confirm that my child has/children have been immunized in accordance with the MA Department of Public Health for their age.

YesNo
IN CASE OF EMERGENCY: I give permission to Temple Emanuel staff members to take any necessary action, such as administering treatment to my child, including allergy medications I have given the school for this purpose, or arranging transport for my child to the nearest hospital to receive appropriate emergency care.

YesNo
I give permission for my child's/children’s image/likeness to be used in any school or community-related publications including Temple Emanuel website and Facebook page (no names are listed)

YesNo
I give permission for my child/children to attend off-site field trips with their class, accompanied by Temple Emanuel teachers/staff/parent chaperones. I understand that dates, times and locations will be announced prior to each trip and that transportation will be provided by hired bus, departing from and returning to Temple Emanuel.

Financial Assistance: Do you anticipate needing tuition assistance?
YesNo

If yes, please contact the Religious School Office or synagogue office for an Abatement Certification form, complete it and return it to the Temple Emanuel Blum Executive Office, c/o Jeff Lurie, Executive Director ( jlurie@templeemanuel.com ). You will be contacted confidentially.