Religious School Enrollment 2024-25 / 5785 - Form

Am Tikvah 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 the Am Tikvah School. Your family receives free synagogue membership for your *first* year in ATS. 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.

	First child in the family:	Additional children in the same family:
Am Tikvah School (ATS) Tuition	$850 each	$700 each
	First year membership with children enrolled at ATS:	Second year and beyond, with or without children enrolled at ATS:
Am Tikvah Congregation Family Membership	$0	$2,650 *

* No one is turned away for lack of funds. Contact Talya to discuss (415) 664-7375.

Enrollment Form Instructions:

If you are a member or already in our database, please LOG INTO YOUR ACCOUNT by clicking the Login button in the top right of the page and entering your email and password. This form will automatically populate some of your information. If you do not remember your password, click Forgot Password to reset it. 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

Please provide contact information for an additional person OTHER THAN A PARENT/GUARDIAN that we will contact in an emergency if we are unable to reach the parent(s) listed above.

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 2024

What pronouns do they use?

Please Select OneShe/Her/HersHe/Him/HisThey/Them/Theirs

* 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 2024

What pronouns do they use?

Please Select OneShe/Her/HersHe/Him/HisThey/Them/Theirs

* 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 2024

What pronouns do they use?

Please Select OneShe/Her/HersHe/Him/HisThey/Them/Theirs

* 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

Does Student #2 have the same doctor & insurance information as Student #1?

Doctor's Name:

Doctor's Phone Number:

Insurance Company

Policy ID Number

Group Number

Student #3

Does Student #3 have the same doctor & insurance information as Student #1?

Doctor's Name:

Doctor's Phone Number:

Insurance Company

Policy ID Number

Group Number

MEDICAL AUTHORIZATIONS

* 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 Education Administrator as my representative in the event of a medical emergency concerning my child.

Please Select OneYes, I agree to emergency medical care for my child(ren).NO, I DO NOT agree to emergency medical care for my child(ren).

* I hereby give my permission for the Rabbi, Executive Director, Director of Education, or Youth Education Administrator to dispense over-the-counter medications such as acetaminophen, ibuprofen, or antihistamines to each named child above.

Please Select OneYes, I agree to allow staff to dispense over-the-counter medication to my child(ren)No, I DO NOT agree to allow staff to dispense over-the-counter medication to my child(ren)

PHOTO RELEASE AUTHORIZATION

Congregation Am Tikvah occasionally uses photographs of Am Tikvah School 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 permission to use my child(ren)'s names and photographs.Yes, I DO NOT give permission to use my child(ren)'s names and photographs.

TUITION AND FEES

Please choose your preferred payment option below. Tuition for the first student is $850 and $700 for each additional student ($150 discount per sibling). 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, 2025.

* Payment Options - 1 Student

Please Select OnePay in Full - $850Pay 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 $94.44, starting Sept or 3 payments of $283.33 every 3 months (Sept, Dec, Mar).

* Payment Options - 2 Students

Please Select OnePay in Full - $1,550Pay 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 $172.22, starting Sept or 3 payments of $516.67 every 3 months in Sept, Dec, and Mar.

* Payment Options - 3 Students

Please Select OnePay in Full - $2,250Pay 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 $250, starting Sept or 3 payments of $750 every 3 months in Sept, Dec, and Mar.

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.

If you're able, please consider donating to our E. Safer Youth Education Fund, which helps to ensure that Am Tikvah School is possible for all, regardless of financial ability.

Would you like to donate to our E. Safer Youth Education Fund?

Scholarship Donation

Donation Amount

Thank you! We look forward to spending time together in the coming year, 5785!

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