Beit Sefer Chadash Enrollment 2022-23 / 5783 - Form

Congregation Am Tikvah
Beit Sefer Chadash "The New School"
Sunday & Hebrew School on the South Side of San Francisco
Note: This form is formatted for a wide screen and may look funny on a phone. It will still work.

Enrollment Form Instructions:

If you are a member or already in our database, please FIRST FIND YOUR RECORD by typing your name into the field above the SHALOM image. This form will automatically populate some of your information.
Note: This function may not work on a phone. If you see the field, try entering your name because, otherwise, the form may erase your entries at the end when you try to submit. If it's not there, don't worry about it. Please excuse these inconveniences as we learn our new ShulCloud database!

Next, please fill out all applicable sections of this enrollment form, for up to two children. If you are enrolling 3 or more students, you will need to complete and submit this form twice. Once you complete the form, you will be prompted to create an account in ShulCloud. This is our synagogue's database. Your information is secure and confidential.

You do not need to be a member of Am Tikvah to enroll your child for their first year of Beit Sefer Chadash. Come give it a try! We look forward to getting to know your whole family! If you are having difficulty with the form, please contact the Youth Programming Director, Talya K. Brass, tbrass@amtikvah.org.

FAMILY IMFORMATION

* Parent/Guardian (1) Name

Parent/Guardian (2) Name

* Parent/Guardian (1) Best Phone Number

Parent/Guardian (2) Best Phone Number

* Parent/Guardian (1) Email

Parent/Guardian (2) Email

Parent/Guardian (1) Street

Parent/Guardian (2) Street (If Different)

Parent/Guardian (1) City

Parent/Guardian (2) City (If Different)

Parent/Guardian (1) State

Parent/Guardian (2) State (If Different)

Parent/Guardian (1) Zip

Parent/Guardian (2) Zip (If Different)

Additional Parent/Guardian Custody Information

Emergency Contact Name

Emergency Contact Cell Phone

Student (1) First Name

Student (2) First Name

Student (1) Last Name

Student (2) Last Name

Enrollment Grade - Student (1)

Enrollment Grade - Student (2)

School Track (1) (See flyer)

My-child-is-in-Grades-TK-2My-child-is-in-Grades-3-7My-child-is-in-Grades-8-10

School Track (2) (See flyer)

My-child-is-in-Grades-TK-2My-child-is-in-Grades-3-7My-child-is-in-Grades-8-10

Student (1) Hebrew Name

Student (2) Hebrew Name

Student (1) Birthday

Student (2) Birthday

ALLERGY INFORMATION

Information for Student (1)

Information for Student (2)

Does Student (1) have any allergies?

Yes. My child has allergies.No. My child has no allergies.

Does Student (2) have any allergies?

Yes. My child has allergies.No. My child has no allergies.

List all food allergies student (1):

List all food allergies student (2):

List all other allergies student (1):

List all other allergies student (2):

Does student (1) have an EpiPen or Inhaler?

Yes-EpiPenNo-EpiPenYes-InhalerNo-Inhaler

All EpiPens at TBO must have photo ID attached.

Does student (2) have an EpiPen or Inhaler?

Yes-EpiPenNo-EpiPenYes-InhalerNo-Inhaler

All EpiPens at TBO must have photo ID attached.

If yes, student (1) EpiPen and/or Inhaler location:

Special carrier on his/her personIn his/her backpackIn the classroom with the teacherOther

If yes, student (2) EpiPen and/or Inhaler location:

Special carrier on his/her personIn his/her backpackIn the classroom with the teacherOther

If other, please explain - student (1).

If other, please explain - student (2).

SCHOOL INFORMATION

Does student (1) have an Individual Education Plan (IEP) 504 or Building Level Plan of any sort in public/private school?

YesNo

If yes, we will contact you to discuss the appropriate accommodations for your child.

Does student (2) have an Individual Education Plan (IEP) 504 or Building Level Plan of any sort in public/private school?

YesNo

If yes, we will contact you to discuss the appropriate accommodations for your child.

Does student (1) have any medical conditions or learning differences or take any medication that could affect their religious school experience?

YesNo

Does student (2) have any medical conditions or learning differences or take any medication that could affect their religious school experience?

YesNo

If yes, please provide details for student (1).

If yes, please provide details for student (2).

Is there anything else you would like to share about student (1)?

Is there anything else you would like to share about student (2)?

FAMILY PUBLICITY PERMISSION

Yes I give my permission.No I do not give my permission.

By clicking yes - you are agreeing that Student's photograph, name, art, written work, voice, or verbal statements may appear in Am Tikvah publicity or publications.

FAMILY MEDICAL EMERGENCY INFORMATION

Doctor's Name:

Doctor's Phone Number:

Insurance Company

Policy ID Number

Group Number

I hereby give permission for my child(ren) to be taken off Synagogue grounds for the purpose of medical attention in the event that I cannot be contacted in an emergency. I authorize and designate the Rabbi, Director of Education, or Youth Programming Director as my representative in the event of a medical emergency concerning my child.

Yes I give my permission.No I do not give my permission.

TUITION AND FEES

Choose one below for each student enrolling. Payment options (including the ability to divide this payment over up to 12 months) will be given on the following page.

Pay in Full Option - Please enroll (Student 1):

TK-2-pay-in-full--725Grade-3-7-pay-in-full--725Grade-8-10-pay-in-full--725

Deposit Only Option - Please enroll (Student 1):

TK-2-pay---deposit--250Grade-3-7---deposit--250Grade-8-10---deposit--250

Pay in Full Option - Please enroll (Student 2):

TK-2nd-pay-in-full--725Grade-3-7-pay-in-full--725Grade-8-10-pay-in-full--725

Deposit Only Option - Please enroll (Student 2):

Grade-TK-2---deposit--250Grade-3-7---deposit--250Grade-8-10---deposit--250

Special Financial Arrangement

Special Financial Arrangement
Am Tikvah Sisterhood has generously approved full and partial scholarships for dues-paying member families!

Please click this option to choose a financial arrangement that is different from paying in full ($725 per student) or paying a deposit ($250 per student). By clicking this option, you will not be charged through this form. Instead, someone will contact you about a special financial arrangement.

Thank you! We look forward to spending time together in the coming year, 5783!

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