TE High School Seminar Registration

Parent Information

Parent 1(Required)

First Name Last Name

Parent 2

First Name Last Name

Cell Phone(Required)

Home Phone

Cell Phone

Home Phone

Email(Required)

Address (if different from student)

Street Address Address Line 2 City State ZIP Code

Address (if different from student and/or parent 1)

Street Address Address Line 2 City State ZIP Code

Are you currently a Temple Emanuel Member?(Required)

Yes

Are you a member of another synagogue? If so, where?

Student's Information

Name(Required)

First Middle Last

Pronouns(Required)

Date of Birth(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

Teen's Cell (if applicable)

Teen's Email (if applicable)

School

Grade (as of Sep 2022)

Medical Information

Are there any dietary restrictions? If yes, what is restricted ?

IMMUNIZATIONS(Required)

I confirm that my teen has been immunized in accordance with the MA Department of Public Health, and has been vaccinated for Covid-19.*

Yes

IMMUNIZATIONS SIGNATURE(Required)

MEDICATIONS(Required)

Does your teen take medications on a regular basis?

Yes

If so, what medications?(Required)

ALLERGIES(Required)

Does your teen have allergies on a regular basis?

Yes

ALLERGY INFORMATION FORM

Allergy Information

Press the + symbol on the right to add information for additional allergies

Allergic To

Reaction

Treatment

I will provide an Epi-pen to the Religious School(Required)

Yes

My teen carries an Epi-pen in their backpack(Required)

Yes

PARENT SIGNATURE(Required)

Learning Support Information

Does your teen have any emotional and/or familial issues of which we should be aware?

Yes

Please describe, and share, any support plans in place:

Does your teen have any learning, attentional, or behavioral issues of which we should be aware?

Yes

Please describe, and share, any support plans in place:

Does your teen have an IEP or 504 Plan?

If yes, please submit a current copy to the Religious School.

Yes

Upload IEP or 504 Plan here(Required)

Max. file size: 512 MB.

Does your teen receive individual support services in the classroom at school?

Yes

Please Describe:

Additional Students

Student 2

Add Another Student

Name(Required)

First Middle Last

Pronouns(Required)

Date of Birth(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Teen's Cell (if applicable)

Teen's Email (if applicable)

School

Grade (as of Sep 2022)

Medical Information

Are there any dietary restrictions? If yes, what is restricted?

IMMUNIZATIONS(Required)

I confirm that my teen has been immunized in accordance with the MA Department of Public Health, and has been vaccinated for Covid-19.*

Yes

IMMUNIZATIONS SIGNATURE(Required)

MEDICATIONS(Required)

Does your teen take medications on a regular basis?

Yes

If so, what medications?(Required)

ALLERGIES(Required)

Does your teen have allergies on a regular basis?

Yes

ALLERGY INFORMATION FORM

Allergy Information

Press the + sumbol on the right to add information for additional allergies

Allergic To

Reaction

Treatment

I will provide an Epi-pen to the Religious School(Required)

Yes

My teen carries an Epi-pen in their backpack(Required)

Yes

PARENT SIGNATURE(Required)

Learning Support Information

Does your teen have any emotional and/or familial issues of which we should be aware?

Yes

Please describe, and share, any support plans in place:

Does your teen have any learning, attentional, or behavioral issues of which we should be aware?

Yes

Please describe, and share, any support plans in place:

Does your teen have an IEP or 504 Plan?

If yes, please submit a current copy to the Religious School.

Yes

Upload IEP or 504 Plan here(Required)

Max. file size: 512 MB.

Does your teen receive individual support services in the classroom at school?

Yes

Please Describe:

Student 3

Add Another Student

Name(Required)

First Middle Last

Pronouns(Required)

Date of Birth(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Teen's Cell (if applicable)

Teen's Email (if applicable)

School

Grade (as of Sep 2022)

Medical Information

Are there any dietary restrictions? If yes, what is restricted?

IMMUNIZATIONS(Required)

I confirm that my teen has been immunized in accordance with the MA Department of Public Health, and has been vaccinated for Covid-19.*

Yes

IMMUNIZATIONS SIGNATURE(Required)

MEDICATIONS(Required)

Does your teen take medications on a regular basis?

Yes

If so, what medications?(Required)

ALLERGIES(Required)

Does your teen have allergies on a regular basis?

Yes

ALLERGY INFORMATION FORM

Allergy Information

Press the + sumbol on the right to add information for additional allergies

Allergic To

Reaction

Treatment

I will provide an Epi-pen to the Religious School(Required)

Yes

My teen carries an Epi-pen in their backpack(Required)

Yes

PARENT SIGNATURE(Required)

Learning Support Information

Does your teen have any emotional and/or familial issues of which we should be aware?

Yes

Please describe, and share, any support plans in place:

Does your teen have any learning, attentional, or behavioral issues of which we should be aware?

Yes

Please describe, and share, any support plans in place:

Does your teen have an IEP or 504 Plan?

If yes, please submit a current copy to the Religious School.

Yes

Upload IEP or 504 Plan here(Required)

Max. file size: 512 MB.

Does your teen receive individual support services in the classroom at school?

Yes

Please Describe:

Student 4

Add Another Student

Name(Required)

First Middle Last

Pronouns(Required)

Date of Birth(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Teen's Cell (if applicable)

Teen's Email (if applicable)

School

Grade (as of Sep 2022)

Medical Information

Are there any dietary restrictions? If yes, what is restricted?

IMMUNIZATIONS(Required)

I confirm that my teen has been immunized in accordance with the MA Department of Public Health, and has been vaccinated for Covid-19.*

Yes

IMMUNIZATIONS SIGNATURE(Required)

MEDICATIONS(Required)

Does your teen take medications on a regular basis?

Yes

If so, what medications?(Required)

ALLERGIES(Required)

Does your teen have allergies on a regular basis?

Yes

ALLERGY INFORMATION FORM

Allergy Information

Press the + sumbol on the right to add information for additional allergies

Allergic To

Reaction

Treatment

I will provide an Epi-pen to the Religious School(Required)

Yes

My teen carries an Epi-pen in their backpack(Required)

Yes

PARENT SIGNATURE(Required)

Learning Support Information

Does your teen have any emotional and/or familial issues of which we should be aware?

Yes

Please describe, and share, any support plans in place:

Does your teen have any learning, attentional, or behavioral issues of which we should be aware?

Yes

Please describe, and share, any support plans in place:

Does your teen have an IEP or 504 Plan?

If yes, please submit a current copy to the Religious School.

Yes

Upload IEP or 504 Plan here(Required)

Max. file size: 512 MB.

Does your teen receive individual support services in the classroom at school?

Yes

Please Describe:

Siblings

Name

Age

Grade

Emergency Information

IN CASE OF EMERGENCY:(Required)

I give permission to Temple Emanuel staff members to take any necessary action, such as administering treatment to my teen, including allergy medications I have given the school for this purpose, or arranging transport for my teen to the nearest hospital to receive appropriate emergency care.

Yes

If possible, I prefer that my teen(s) be taken to the following hospital:(Required)

If possible, please contact the following physician:(Required)

Physician Phone(Required)

Health Insurance Provider/Policy #:

Emergency Contacts (other than parents)

Emergency Contact Information(Required)

Name

Phone

Relationship to Teen

PARENTAL PHOTO AUTHORIZATION – Agreement for 2022/2023 School year:

Images(Required)

I give permission for my teen's image/likeness to be used in any school or community-related publications including Temple Emanuel website and Facebook page (no names are listed)

Yes

Other Information

Financial Assistance: Do you anticipate needing tuition scholarship assistance?(Required)

Yes

If yes, please contact the Religious School Office or Main Office for an Abatement Certification form, complete it and return it to the Temple Emanuel office, c/o Tim Mahoney, President (tmahoney@templeemanuel.com). You will be contacted confidentially.

Signature(Required)

How would you prefer to pay?(Required)

Pay Online

Pay by Check

TE High School Seminar Fee (Required)

Price: $360.00

3% Online Processing Fee(Required)

Price: $0.00

Total

Payment Method(Required)

American Express

Discover

MasterCard

Visa

Card Number Expiration Date Security Code Cardholder Name

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TE High School Seminar Registration

Parent Information

Student's Information

Medical Information

ALLERGY INFORMATION FORM

Learning Support Information

Additional Students

Medical Information

ALLERGY INFORMATION FORM

Learning Support Information

Medical Information

ALLERGY INFORMATION FORM

Learning Support Information

Medical Information

ALLERGY INFORMATION FORM

Learning Support Information

Emergency Information

Emergency Contacts (other than parents)

PARENTAL PHOTO AUTHORIZATION – Agreement for 2022/2023 School year:

Other Information

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