Beit Sefer Chadash Enrollment 2023-24 / 5784 ~ New Family Registration - Form

Congregation Am Tikvah
Beit Sefer Chadash "The New School"
Sunday & Hebrew School on the South Side of San Francisco

You do not need to be a member of Am Tikvah to enroll your child for their *first* year of Beit Sefer Chadash. Your family receives free synagogue membership for your *first* year as in 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 Am Tikvah office at 415.586.8833 or office@amtikvah.org.

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. Next, please fill out all applicable sections of this enrollment form, for up to three children. If you are enrolling more than 3 students, please call the office to register to add the additional students with the sibling discount. Once you complete the form, you will be prompted to create an account in ShulCloud if you do not already have one. This is our synagogue's database, used for processing payments. Your information is secure and confidential. If you are having difficulty with the form, please contact the Am Tikvah office at 415.586.8833 or office@amtikvah.org.

FAMILY INFORMATION

Adult #1

* First Name

* Last Name

* Mobile Phone Number

* Email

* Street Address

* City

* State

Zip

* Is there a second parent/guardian?

Adult #2

* First Name

* Last Name

* Mobile Phone Number

* Email

Does Adult #2 have a different address than Adult #1?

NoYes

Street Address

City

State

Zip

Additional Parent/Guardian Custody Information

EMERGENCY CONTACT INFORMATION

Emergency Contact Name

Relationship to Student

Emergency Contact Cell Phone

* How many Children are you enrolling?

Student #1

* Full Name

Nickname

* DOB

Hebrew Name

* Grade Level in Fall 2023

* Does student have any allergies?

List all food allergies:

List all other allergies:

Does this student have an EpiPen?

* EpiPen location:

If other, please explain.

Student #2

* Full Name

Nickname

* DOB

Student (2) Hebrew Name

* Grade Level in Fall 2023

* Does this student have any allergies?

List all food allergies:

List all other allergies:

* Does this student have an EpiPen?

* EpiPen location:

If other, please explain.

Student #3

* Full Name

Nickname

* DOB

Hebrew Name

* Grade Level in Fall 2023

* Does this student have any allergies?

List all food allergies:

List all other allergies:

* Does student have an EpiPen?

* EpiPen location:

If other, please explain.

SCHOOL INFORMATION

Student #1

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

Please briefly describe IEP or 504 details.

Upload a copy of student's 504 or IEP

* Does student have any medical conditions or learning differences, or take any medication (i.e. inhaler) that could affect their religious school experience?

Please provide details for student #1.

Is there anything else you would like to share about student #1 that will help us create a positive learning environment?

Student #2

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

Please briefly describe IEP or 504 details.

Upload a copy of student's 504 or IEP

* Does student #2 have any medical conditions or learning differences or take any medication (i.e. inhaler) that could affect their religious school experience?

Please provide details for student #2.

Is there anything else you would like to share about student #2 that will help us create a positive learning environment?

Student #3

Does student #3 have an Individual Education Plan (IEP) 504 or Building Level Plan of any sort in public/private school?

Please briefly describe IEP or 504 details.

Upload a copy of student's 504 or IEP

* Does student #3 have any medical conditions or learning differences or take any medication (i.e. inhaler) that could affect their religious school experience?

Please provide details for student #3.

Is there anything else you would like to share about student #3 that will help us create a positive learning environment?

FAMILY MEDICAL EMERGENCY INFORMATION

Student #1

Doctor's Name:

Doctor's Phone Number:

Insurance Company

Policy ID Number

Group Number

Student #2

Doctor's Name:

Doctor's Phone Number:

Insurance Company

Policy ID Number

Group Number

Student #3

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, Executive Director, Director of Education, or Youth Programming Director as my representative in the event of a medical emergency concerning my child.

Please Select OneYes, I give my permission.No I do not give my permission.

PHOTO RELEASE

Congregation Am Tikvah occasionally uses photographs of Beit Sefer Chadash students taken at events in its publications and on its Website.

I hereby grant permission to Am Tikvah to use my child(ren)'s image and voice, first name, art, written work, or verbal statements on its website, social media platforms, or in other official printed and online publications without further consideration, and I acknowledge Am Tikvah has right to crop or treat any images at its discretion. I also acknowledge that Am Tikvah may choose not to use my child(ren)'s image at this time, but may do so at its own discretion at a later date. Am Tikvah reserves the right to discontinue use of images without notice. I also understand that once my child(ren)'s image is posted on Am Tikvah's website, the image can be downloaded.

Therefore, I agree to indemnify and hold harmless from any claims the Am Tikvah Board of Directors and All Employees of Am Tikvah.

Please Select OneYes, I give my consent.No, I do not give my consent.

TUITION AND FEES

Please choose your preferred payment option below. Tuition for the first student is $725 and $580 for each additional student (20% sibling discount). If you choose to pay in installments, you can set up your payments on the next page. You must pay in full by May 31, 2024.

* Payment Options - 1 Student

Please Select OnePay in Full - $725Pay in InstallmentsSpecial Financial Arrangement

Please describe your financial considerations (no tax returns are required).

On the next screen, please choose to pay 9 monthly payments of $80.56, starting Sept or 3 payments of $241.67 every 3 months (Sept, Dec, Mar).

* Payment Options - 2 Students

Please Select OnePay in Full - $1305Pay in InstallmentsSpecial Financial Agreement

Briefly describe your financial constraints (no tax returns are required).

On the next screen, please choose to pay 9 monthly payments of $145, starting Sept or 3 payments of $435 every 3 months in Sept, Dec, and Mar.

* Payment Options - 3 Students

Please Select OnePay in Full - $1885Pay in InstallmentsSpecial Financial Agreement

Briefly describe your financial constraints (no tax returns are required).

On the next screen, please choose to pay 9 monthly payments of $209.44, starting Sept or 3 payments of $628.33 every 3 months in Sept, Dec, and Mar.

Am Tikvah Sisterhood has generously approved partial scholarships for dues-paying member families!

Please choose the "Special Financial Arrangement" option to choose a financial arrangement that is different from paying the full cost per child. By choosing this option, you will not be charged through this form. Instead, you will be asked to enter a short written explanation of your financial situation (no tax forms necessary). Then, the office will contact you about a special financial arrangement. The information you write will not be seen by anyone other than office staff.

Thank you! We look forward to spending time together in the coming year, 5784!

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