<p> 2012 – 2013 Religious School Student Registration Information </p><p>IMPORTANT: Please complete the following information for each child: □ University Synagogue Campus □ Adventures In Jewish Education Camp</p><p>(Please Print) Student’s Name: </p><p>______Last First Middle</p><p>Hebrew Name ______</p><p>Birth Date: ______/______/______Male ____ Female ____</p><p>Enter grade or select class at US: ______</p><p>New student to University Synagogue: Yes ______No ______</p><p>Name of Secular School and City: ______</p><p>Parent/Guardian ______Jewish ( yes / no )</p><p>Home Phone: ______(Cell Phone) ______</p><p>(Work Phone)______E-Mail Address: ______</p><p>Address: ______Street City Zip Code</p><p>Parent/Guardian ______Jewish ( yes / no )</p><p>Home Phone: ______(Cell Phone)______</p><p>(Work Phone) ______E-Mail Address: ______</p><p>Address: ______Street City Zip Code</p><p>Student’s Physician: ______1 Phone Number: ______Address: ______</p><p>Student’s Dentist: ______Phone Number: ______Address: ______</p><p>STUDENT MEDICAL</p><p>Does your child have any allergies or conditions that may require immediate or emergency care? Yes ____ No ____</p><p>If “yes,” please list and describe treatment in the space provided below: ______</p><p>Does your child have any medical conditions or take any medication(s)? Yes ___ No ____ </p><p>If “yes,” please list and describe in the space provided below: ______</p><p>EMERGENCY CONTACTS </p><p>Name: ______Relationship: ______</p><p>Home Phone: ______Cell/Work Phone: ______</p><p>Name: ______Relationship: ______</p><p>Home Phone: ______Cell/Work Phone: ______</p><p>MEDICAL INSURANCE</p><p>2 Insurance Company ______ID Number ______Policy Number______Name of Policy Holder______</p><p>MEDICAL RELEASE AUTHORIZATION</p><p>In case of an accident or serious illness, I request that University Synagogue contact me immediately. If the school is unable to reach me, I hereby authorize the Religious School, or its authorized agent, to secure proper treatment for my child.</p><p>Yes ______No ______</p><p>______(Signature of Parent/Guardian) (Date)</p><p>HELP US MEET YOUR CHILD’S NEEDS</p><p>In an effort to provide the best educational experience for your child, please provide any information pertaining to social, physical or emotional issues that may be a factor in the classroom. Please include strengths, talents and interests as well as challenges. ______</p><p>ROOM PARENTS Parents who would like to participate in their child’s Jewish education by helping to plan holiday, family Shabbat programs and special activities in the Religious School.</p><p>______Yes, I would like to participate as a room parent.</p><p>______Grade</p><p>Parent Name(s): ______</p><p>WEEKLY RELIGIOUS SCHOOL UPDATE E-MAIL FLYERS</p><p>3 In an effort to preserve our environment, the University Synagogue Religious School is doing its part by joining global efforts and going “green.” Most school information will be sent via an E- Flyer E-mail on a weekly basis. Please provide a current e-mail address(s) to which you would like this information delivered.</p><p>E-Mail Address: ______</p><p>E-Mail Address: ______</p><p>RELIGIOUS SCHOOL DIRECTORY INFORMATION RELEASE FORM</p><p>In an effort to provide communication with your child’s teacher(s), assist room parents with coordinating and announcing school events as well as offer information for those interested in carpooling, we ask that parents provide the following information for the Religious School Directory. </p><p>This information will only be used for Religious School purposes.</p><p> No, I would not like to participate</p><p> Yes, I would like to participate in the Religious School Directory</p><p>Please submit the following information:</p><p>Name: ______</p><p>Address: ______</p><p>City: ______Zip Code______</p><p>Home Phone: ( ) ______Cell Phone ( ) ______</p><p>E-Mail Address: ______E-Mail Address: ______</p><p>I hereby give University Synagogue Religious School permission to submit the information provided in the 2012-2013 Religious School Directory. </p><p>Name: ______Date: ______</p><p>Signature: ______</p><p>PARENTAL CONSENT FOR STUDENT PHOTO RELEASE</p><p>4 During the school year special events and class activities at the US Religious School are illustrated in the local newspapers and magazines. We also use student photos in our school curriculum when communicating to other students across the globe in our grade level pen pals program. </p><p>The US Religious School requires parental permission in order to use photos that include your child with any school or classroom publicity. </p><p>I, ______(Parent’s Name) give University Synagogue Religious School Permission to use photos of class or activity/special events that include my child for publication or curriculum purposes during the 2012-2013 school year.</p><p>______(Parent’s Signature) (Date)</p><p>PREVIOUS RELIGEOUS SCHOOL SETTINGS You have my permission to contact any previous Religious School settings where our child has been enrolled. Any such information provided to the Religious School is kept strictly confidential and is used solely for the purpose of determining the best placement and setting for the child. </p><p>Yes / no (circle appropriate) ______(parent signature)</p><p>Name of Previous facility: ______</p><p>Contact Person: ______</p><p>Phone Number: ______Email: ______</p><p>Dates attended: ______</p><p>PROFESSIONAL SERVICE PROVIDERS You have my permission to contact current or previous professional service providers for our child (for example, speech therapist, physician, physical therapist). Any such information provided to the Religious School is kept strictly confidential and is used solely for the purpose of determining how best to serve the child’s needs while the child is enrolled and attends the Religious School. Parent(s) will be notified prior to contact.</p><p>Yes / no (circle appropriate) ______(parent signature)</p><p>Name of Service Provider: ______</p><p>Contact Person: ______</p><p>Phone Number: ______Email: ______</p><p>Dates attended: ______</p><p>Parent Name(s) ______</p><p>5</p>