The Jewish Experience @ Central Synagogue- Beth Emeth  Individual Student/ Family Registration Form.
2021-2022/5782                                                                                                                                
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Welcome!
We are thrilled to have your child take part in our educational program at The Jewish Experience. Contact Karen Feit at educator@csbeli.org or 516-766-4300 with any questions or concerns.

Book, Materials and Special Events Fee Information 2021-2022:
CSBE Members: $180 for the first child, $100 each additional child. [$480 maximum per family]  Credit Card Pricing: $183.60, $285.60,$387.60,$489.60.                                                      
Non members: $360 per child [maximum $500 per family]
CSBE MEMBERSHIP IS REQUIRED ONCE THE OLDEST CHILD IN THE FAMILY BEGINS THIRD GRADE
All checks should be made payable to Central Synagogue - Beth Emeth and mailed to 430 DeMott Avenue, Rockville Centre.

Please note that a medical treatment authorization form must be filled out each year.  Forms should be completed at
https://forms.gle/Dqtg7SMBhekKVWVDA
Child's Name (First and Last) *
Child's Hebrew Name
Date of Birth *
MM
/
DD
/
YYYY
Name of School Attending *
Grade in September 2021 *
Parent # 1 Name *
Parent # 2 Name
Parent # 1 Hebrew Name
Parent # 2 Hebrew Name
Parent  #1 E-mail Address *
Parent  #2 E-mail Address
Parent #1 Mobile Phone *
Parent #2  Mobile Phone
Parent #1 Address *
Parent #2 Address or SAME
Parent #1 Home Phone *
Parent #2 Home Phone or Same
Parent #1  Work Phone *
Parent #2 Work Phone
Weekend Emergency Contact
Name *
Relationship *
Mobile Phone *
Home Phone *
Weekday Emergency Contact
Name *
Relationship *
Mobile Phone *
Home Phone *
Siblings ( Not Enrolled in The Jewish Experience )
Names and Ages
Background Information
Does Your Child Have ( Check all that apply)
Other? Please Explain
Does your child have any illnesses, allergies, special family arrangements, or school obligations that may affect regular attendance?  
Do you have any special concerns or requests that you would like to share with us about your child?
 I would like to volunteer for:
I have a special talent that I could share with classes in the Jewish Experience. Please explain below.
Please Note: Membership in CSBE is required when the oldest child in the family begins Third Grade.
Please check the box below that best describes your current affiliation with CSBE. *
Required
Please contact me regarding membership
Please print your name below if you do not want photos of your child published on Central Synagogue - Beth Emeth websites, in newspapers, other media or social networking sites. (Note: Students will not be identified individually in any photos.)
I understand that my child may be using the Internet during the school year and must demonstrate responsible behavior when using the Internet.                                                                               ( Please type yes and your child's name in the box below) *
Parent/ Guardian Signature *
Parent/ Guardian Signature
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