2019/20 Hebrew School, Tichon & Confirmation Registration/Enrollment Form Grades PreK through 10

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Required registration and enrollment form for 2019/20 Hebrew School year. Please complete for each child/student in your household. Direct questions to bglickman@ohev.org or call 215-322-9597. Thank you and welcome to an exciting year of Jewish learning!

Student's First Name *

Student's Last Name *

Age as of September 1, 2019 *

Preschool/PreK only, Date of Birth:

Secular School Grade as of September 2019, please check: *

Preschool/PreK

Kindergarten

1st grade

2nd grade

3rd grade

4th grade

5th grade

6th grade

7th grade

8th/9th grade

10th grade/Confirmation only

Other:

Required

Option 1

Clear selection

If you would like assistance obtaining a Hebrew name please check here.

Yes, contact me about obtaining a Hebrew name for my student!

Parent 1/Guardian 1 Name *

Parent 2/Guardian 2 Name *

Primary Email *

Secondary Email

Please send emails to both primary and secondary email addresses:

Yes

Primary Contact/Phone Number *

Primary Mailing Address *

Student lives with *

Both Parents

Parent 1

Parent 2

Grandparents

Other:

Please check all that apply:

Wears glasses or contact lenses

Speech concerns

Comprehension challenges

Short attention span

Hearing concerns

Fine motor difficulties

Easily upset

Dyslexia

Reads below grade level

Behavioral concerns

Is challenged in the school environment socially

Is challenged by the school environment emotionally

Is challenged by the school environment academically

Other:

I would like to schedule a meeting with the Inclusion Facilitator. *

Yes

List any allergies or other health concerns we should be aware of here. *

If your child is currently taking medication, please list here.

Emergency Contact 1, other than parent, include name, phone number and relationship. *

Emergency Contact 2, other than parent, include name, phone number and relationship.

Name of Physician and telephone number *

Name of Dentist and telephone number *

Medical Insurance Company Name and Group # *

In case of a medical emergency, I authorize Ohev Shalom staff to obtain emergency medical treatment for my child. I understand that every effort will be made to contact me immediately. *

Yes

Hebrew School ONLY Photo/Video Release - permission is granted to Ohev Shalom of Bucks County Hebrew School to take photographs and videos of my child and to use/publish photographs and videos for Hebrew School only purposes in school communications, on social media, on our website, etc. *

YES

Ohev Shalom of Bucks County Photo/Video Release - permission is granted to Ohev Shalom of Bucks County, its representatives, employees, and local media the right to take photographs and videos of my child and to use/publish photographs and videos in print and/or electronically. I agree that Ohev Shalom of Bucks County may use such photographs of my child with or without names and for any lawful purpose including social media, publicity, illustration, advertising, marketing and web content. *

YES

Electronic signature, by signing below I agree that my electronic signature is the legal equivalent to my manual signature. *

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