TBEMC Religious School Enrollment 2023 - 2024
Thank you in advance for completing this important document and for providing us with the privilege of offering a Jewish education to your child.  Please complete a separate form for each child in your family.
Is your child new to TBEMC's religious school? *
Student Name (First, Middle) *
Student (Last Name) *
Home Address: Street, City, State, Zip *
Date of Birth *
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Gender *
Grade Level *
Hebrew/ Jewish Name *
If you do not know your child's Jewish Name please type Not Certain.
Parent Name 1 *
Parent 1 Phone # *
Parent Name 2
Parent 2 Phone #
Home Email Address 1 *
Home Email Address 2
Emergency Contact Name *
Emergency Contact Number *
Does the student have any allergies?  Please be specific and include any food and contact allergies. *
Does your child use an EpiPen? *
What are the emergency steps you would like us to take in the event of an allergy attack?
Does the student have any medical allergies?  Please be specific. *
Please note any current medications.
Child may be given Tylenol? *
Child may be given Advil? *
Physician Name *
Physician Telephone Number *
Please provide any additional health information that you think is important for us to know.
Is there any special needs information that you would like to share to help us to provide appropriate educational services to your child?
Medical Emergency Release:  I hereby give my permission to the physician or medical professional selected by the staff to secure proper treatment for my child which I understand might include hospitalization, injections, anesthesia or surgery.  I recognize that I will be responsible for any costs incurred for this treatment. I have read and fully agree to the medical liability form above.  Please sign your name and include the date, indicating your agreement: *
Public Relations/ Media Release:  From time to time, Temple Beth El Mekor Chayim shares with our local community exciting events and programs in which our students participate.  This includes press releases to the local papers as well as publicity on the temple website, bulletin, Facebook, Instagram, and Youtube channel. We will not publish the names of students along with the photos.  Please indicate if you agree to this these media release terms. *
Would you or your significant other be interested in being the room parent? *
Signature of the Person Completing this Form: *
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