Beth El Religious School Registration Form
Congregation Beth El, 8902 Mesa Drive, Austin TX 78759
Tel: 512-231-0266 * www.bethelaustin.org * info@bethelaustin.org 
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Email *
Student Information
Student Name *
Hebrew Name
Birthdate *
MM
/
DD
/
YYYY
School Name *
School Grade *
Parent Information
Mother's first and last name *
Mother's Hebrew name
Phone Number *
Mother's Email *
Father's first and last name
Father's Hebrew name
Phone Number *
Father's Email *
Address *
2nd address (if necessary)
Medical/Learning Needs *
Required
Allergies - please explain
Dietary Restrictions - please explain
Learning Issues - please explain
Other concerns - please explain:
Emergency Contacts
Please provide the following information in case parent(s) cannot be contacted
Emergency Contact 1 - First and last name *
Emergency Contact 1 - Phone number *
Emergency Contact 2 - First and last name
Emergency Contact 2 - Phone number
I give permission to the above person(s) to pick-up and drop off my child. *
Required
Field Trip Permission
I AUTHORIZE my child/children to participate in Beth El Religious School field trips and programs. I agree to hold Congregation Beth El (including its board, officers, staff and volunteers) harmless from any and all claims that may arise out of his/her/their participation in school trips and programs. *
Photo/Video Release
I give permission for my child(ren)’s photograph or video image to be published in any form of media, via print or electronic (e.g. video, internet, synagogue web site) *
Tuition Payment
We offer three options to cover the cost of the school tuition.  For security reasons, if you select options 2 or 3, our tresurer will contact you to collect the credit card information to be used to make scheduled future payments.  Thank you.  
Tuition Payment *
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