The Zelda & Herman Schwartz Hebrew School
of Temple Sholom

Pre Registration 2011-2012

Student Information
Student Name:
 Gender:
male female
Date of Birth:
Public School Grade as of Sept.2011:
 Name of School child attends:
Home Address:
Home Phone number:
Child's Hebrew Name:
Parent/Guardian Information
1. Parent/Guardian Name:
 2. Parent/Guardian Name:
Work Phone number:
 Work Phone number:
Parent 1 Cell Phone number:
 Cell Phone number:
Parent 1 e-mail address:
 Parent 2 e-mail address:
Emergency Contact Information
1. Name:
 2. Name:
Phone number:
 Phone number:
Authorized Pickup Information
1. Name:
 2. Name:
Phone number:
 Phone number:
relationship to child:
 relationship to child:
Medical Information
Please inform us of any allergies, medical conditions, learning needs, or anything you feel we should be aware of so that we may serve your child to the best of our abilities:
Doctor's name:
 Dentist's name:
Doctor's phone #:
 Dentist's Phone number:
Medical Insurance Company
 Policy#:
Group #:
In case of emergency, I authorize the staff of Temple Sholom to obtain emergency medical treatment for my child.I understand that all efforts will be made to contact me or my emergency contacts immediately.
Field Trip Consent Form
I give permission for my Child/Children to participate fully in all activities and/or field trips with the Zelda & Herman Schwartz Hebrew School of Temple Sholom during the 2011-2012 school year.
Parent/Guardian Name
Photo/Video Authorization Form
I give permission for my Child/Children to appear in any photographs or video, or Temple Web site to be used by Temple Sholom and the Hebrew School for publicity / marketing/ or advertising purposes. No personal information shall be given out identifying a student’s name, age, or grade.
Parent/Guardian Name
 

BUS transportation is available.

Hebrew School families become full Temple members which includes High Holiday tickets for the immediate family.