Religious School 2022-23/5783 Enrollment

Rabbi Albert I. Gordon Religious School
Enrollment for (K-5^th) and Chai 385 (6^th-8^th)
2022-2023/5783

Schedule of Classes

Gan (K) & Alef (1^st): Sunday, 9:30 am – noon
Bet (2^nd) – Hay (5^th): Sunday, 9:30 am – noon and Thurs 4-6 pm
Chai 385 (6^th, 7^th): Sunday, 9:30 am – noon and Tuesday 4-6 pm
Chai 385 (8^th): Sunday, 9:30 am – noon and/or Tuesday 4-6 pm

Student's Information

Name(Required)

First Middle Last

Gender/ Preferred Pronoun(Required)

Date of Birth(Required)

Age (as of Sept. 2022)(Required)

Child's Hebrew Name(Required)

Has Hebrew Name

Does not yet have a Hebrew Name

Hebrew Name(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

Child's Cell (if applicable)

Child's Email (if applicable)

Secular School

Grade (as of Sep 2022)

For Chai 385 8th Graders, what day(s)?

Tuesday

Sunday

Both Tuesday & Sunday

Bar/ Bat/ B'nei Mitzvah date, if known

Attending Jewish Day or Overnight Camp in summer of 2022?

Yes

If so, where?

Previous Jewish Education: Has your child attended another synagogue or day school?

Yes

If so, where?

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

Religious Background

If the student's mother is not Jewish or if student is adopted, has child's Jewish identity been ritually affirmed?(Required)

Yes

N/A

If so, where?(Required)

Date(Required)

Are you currently a Temple Emanuel Member?(Required)

Yes

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

OTHER CARETAKERS (i.e. nanny, babysitter, grandparent) we should know about. Include name and phone number(s).

Medical Information

IMMUNIZATIONS(Required)

I confirm that my child 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 child take medications on a regular basis?

Yes

If so, what medications?(Required)

ALLERGIES(Required)

Does your child 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 child carries an Epi-pen in their backpack(Required)

Yes

PARENT SIGNATURE(Required)

Class Placement Policy Information

Would you like to provide input for your child's Class Placement?

Our objective is for every student to be successful in a supportive and engaging educational setting. Class placement is thoughtfully considered, taking into account: • Class size and gender balance • Academic strengths and learning styles • Peer relationships • Individual learning needs. Parents may use the space below to offer input regarding class placement, such as learning style and a brief list of peers who would enhance their school experience. Final decision on class placement will be made by the Religious School/Chai385 Director.

Yes

Class Placement Comments and Additional Information

Learning Support Information

Does your child 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 child 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 child 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: 700 MB.

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

Yes

Please Describe:

I give permission for the Religious School/Chai385 Director to communicate with my child’s secular school teacher to share strategies for supporting my child’s learning.(Required)

Yes

Parent Signature/ Initials(Required)

Additional Students

Student 2

Add Another Student

Name(Required)

First Middle Last

Gender/ Preferred Pronoun(Required)

Date of Birth(Required)

Age (as of Sept. 2022)(Required)

Child's Hebrew Name(Required)

Has Hebrew Name

Does not yet have a Hebrew Name

Hebrew Name(Required)

Address(Required)

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

Child's Cell (if applicable)

Child's Email (if applicable)

Secular School

Grade (as of Sep 2022)

For Chai 385 8th Graders, what day(s)?

Tuesday

Sunday

Both Tuesday & Sunday

Bar/ Bat/ B'nei Mitzvah date, if known

Attending Jewish Day or Overnight Camp in summer of 2022?

Yes

If so, where?

Previous Jewish Education: Has your child attended another synagogue or day school?

Yes

If so, where?

Medical Information

IMMUNIZATIONS(Required)

I confirm that my child 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 child take medications on a regular basis?

Yes

If so, what medications?(Required)

ALLERGIES(Required)

Does your child 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 child carries an Epi-pen in their backpack(Required)

Yes

PARENT SIGNATURE(Required)

Class Placement Policy Information

Would you like to provide input for your child's Class Placement?

Yes

Class Placement Comments and Additional Information

Learning Support Information

Does your child 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 child 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 child 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: 700 MB.

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

Yes

Please Describe:

I give permission for the Religious School/Chai385 Director to communicate with my child’s secular school teacher to share strategies for supporting my child’s learning.(Required)

Yes

Parent Signature/ Initials(Required)

Student 3

Add Another Student

Name(Required)

First Middle Last

Gender/ Preferred Pronoun(Required)

Date of Birth(Required)

Age (as of Sept. 2022)(Required)

Child's Hebrew Name(Required)

Has Hebrew Name

Does not yet have a Hebrew Name

Hebrew Name(Required)

Address(Required)

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

Child's Cell (if applicable)

Child's Email (if applicable)

Secular School

Grade (as of Sep 2022)

For Chai 385 8th Graders, what day(s)?

Tuesday

Sunday

Both Tuesday & Sunday

Bar/ Bat/ B'nei Mitzvah date, if known

Attending Jewish Day or Overnight Camp in summer of 2022?

Yes

If so, where?

Previous Jewish Education: Has your child attended another synagogue or day school?

Yes

If so, where?

Medical Information

IMMUNIZATIONS(Required)

I confirm that my child 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 child take medications on a regular basis?

Yes

If so, what medications?(Required)

ALLERGIES(Required)

Does your child 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 child carries an Epi-pen in their backpack(Required)

Yes

PARENT SIGNATURE(Required)

Class Placement Policy Information

Would you like to provide input for your child's Class Placement?

Yes

Class Placement Comments and Additional Information

Learning Support Information

Does your child 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 child 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 child 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: 700 MB.

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

Yes

Please Describe:

I give permission for the Religious School/Chai385 Director to communicate with my child’s secular school teacher to share strategies for supporting my child’s learning.(Required)

Yes

Parent Signature/ Initials(Required)

Student 4

Add Another Student

Name(Required)

First Middle Last

Gender/ Preferred Pronoun(Required)

Date of Birth(Required)

Age (as of Sept. 2022)(Required)

Child's Hebrew Name(Required)

Has Hebrew Name

Does not yet have a Hebrew Name

Hebrew Name(Required)

Address(Required)

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

Child's Cell (if applicable)

Child's Email (if applicable)

Secular School

Grade (as of Sep 2022)

For Chai 385 8th Graders, what day(s)?

Tuesday

Sunday

Both Tuesday & Sunday

Bar/ Bat/ B'nei Mitzvah date, if known

Attending Jewish Day or Overnight Camp in summer of 2022?

Yes

If so, where?

Previous Jewish Education: Has your child attended another synagogue or day school?

Yes

If so, where?

Medical Information

IMMUNIZATIONS(Required)

I confirm that my child 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 child take medications on a regular basis?

Yes

If so, what medications?(Required)

ALLERGIES(Required)

Does your child 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 child carries an Epi-pen in their backpack(Required)

Yes

PARENT SIGNATURE(Required)

Class Placement Policy Information

Would you like to provide input for your child's Class Placement?

Yes

Class Placement Comments and Additional Information

Learning Support Information

Does your child 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 child 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 child 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: 700 MB.

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

Yes

Please Describe:

I give permission for the Religious School/Chai385 Director to communicate with my child’s secular school teacher to share strategies for supporting my child’s learning.(Required)

Yes

Parent Signature/ Initials(Required)

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 child, including allergy medications I have given the school for this purpose, or arranging transport for my child to the nearest hospital to receive appropriate emergency care.

Yes

If possible, I prefer that my child/children 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 Child

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

Images(Required)

I give permission for my child's/children’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

Field Trips(Required)

I give permission for my child/children to attend off-site field trips with their class, accompanied by Temple Emanuel teachers/staff/parent chaperones. I understand that dates, times and locations will be announced prior to each trip. Students may walk to a local destination or be transported by hired bus, departing from and returning to Temple Emanuel.

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)

Date(Required)