2023/24 Hebrew School/Tichon/Confirmation Registration Form

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Please complete a form for each child you are registering.

Student's First Name *

Student's Last Name *

Hebrew Name if known *

Age as of September 2023 *

Birthdate *

YYYY

Secular School Grade as of September 2023 *

PreK

Kindergarten

Required

Secular School Name *

Parent 1/Guardian 1 Name *

Parent 2/Guardian 2 Name *

Primary Email *

If you have a secondary email, please indicate here.

Primary Contact/Phone Number *

If you would you like to receive weekly Chai Lites via text message please enter your cell phone number here.

Student lives with *

Both Parents/Guardians

Parent,Guardian 1

Parent/Guardian 2

Other:

Physical Mailing Address

Please check all that apply:

Anxiety

Auditory processing sensitivity

Behavioral concerns including short attention span

Comprehension challenges

Fine motor challenges

Is challenged by the school environment socially

Prefer seating for instruction near teacher

Reads below grade level

Sensory sensitivity to loud noises

Speech concerns

Other:

I would like to schedule a meeting with the Education Director and/or Inclusion Facilitator to discuss accommodations for my child. *

Yes

My child has an HSAP and I would to meet with the Inclusion Facilitator to revise. (if no, all accommodations will continue as indicated.)

Yes

Clear selection

If your child has any allergies or other health concerns we should be aware of, please list here. Please submit required copies of allergy forms to the office. *

If your child is currently taking medication, please list name of medication, dose and schedule.

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

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

List the names other than the emergency contacts who your child can be released to.

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

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

Clear selection

I give permission for my student to be included in a class list.

YES

Clear selection

Remind Participation: We will be using Remind for text communication. We will use the system for emergency closings and to remind about upcoming programs. Families will be automatically signed up into their student's class group.

I do not want to be included in the Remind text updates.

Clear selection

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

Submit

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