Religious School 2021-22/5782 Enrollment

Rabbi Albert I. Gordon Religious School
Enrollment for (K-5^th) and Chai 385 (6^th-8^th)
2021-2022/5782

Schedule of Classes

Gan (K) & Alef (1^st): Sunday, 10 am – noon
Bet (2^nd) – Hay (5^th): Sunday, 10 am – noon and Thurs 4-6 pm
Chai 385 (6^th, 7^th): Sunday, 10 am – noon and Tuesday 4-6 pm
Chai 385 (8^th): Sunday, 10 am – noon and/or Tuesday 4-6 pm

Religious School Enrollment Form

Parent Information - Parent 1
Last Name*
First Name*
Home Phone
Cell Phone*
Work Phone
Email*
Address (if different from student)
Street Address City State ZIP Code
Religious Background
Parent Information - Parent 2
Last Name
First Name
Home Phone
Cell Phone
Work Phone
Email
Address (if different from student and/or parent 1)
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Religious Background
If the student's mother is not Jewish or if student is adopted, has child's Jewish identity been ritually affirmed?
- Yes
- No
- N/A
Where?
Date
MM slash DD slash YYYY
Are you currently a Temple Emanuel Member?*
- Yes
- No
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).
Student's Information
Last Name*
First Name*
MI
Gender/ Preferred Pronoun
Date of Birth*
MM slash DD slash YYYY
Age (as of Sept. 2021)
Hebrew Name
Address*
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 2021)
For Chai 385 8th Graders, what day(s)?
- Tuesday
- Sunday
- Both Tuesday & Sunday
Bar/ Bat Mitzvah date, if known
Attending Jewish Day or Overnight Camp in summer of 2021?
- Yes
- No
If so, where?
Previous Jewish Education: Has your child attended another synagogue or day school?
- Yes
- No
If so, where?
Medical Information
IMMUNIZATIONS*
I confirm that my child has been immunized in accordance with the MA Department of Public Health, and has been vaccinated for Covid-19, as eligible for their age.
- Yes
- No
IMMUNIZATIONS SIGNATURE*
MEDICATIONS*
Does your child take medications on a regular basis?
- Yes
- No
If so, what medications?
ALLERGIES*
Does your child have allergies on a regular basis? If so, please fill out the Allergy Information Form.
- Yes
- No
ALLERGY INFORMATION FORM
Student's Name
First Last
Grade
Allergy (1)*
Allergic To Reaction Treatment
Allergy (2)
Allergic To Reaction Treatment
Allergy (3)
Allergic To Reaction Treatment
I will provide an Epi-pen to the Religious School
- Yes
- No
My child carries an Epi-pen in their backpack
- Yes
- No
PARENT SIGNATURE*
Class Placement Policy Information
Would you like to provide input for your child's Class Placement?
- Yes
- No
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.
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
- No
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
- No
Please describe, and share any support plans in place:
Does your child have an IEP or 504 Plan?
- Yes
- No
If yes, please submit a current copy to the Religious School.
Upload IEP or 504 Plan here
Max. file size: 512 MB.
Does your child receive individual support services in the classroom at secular school?
- Yes
- No
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.*
- Yes
- No
Parent Signature/ Initials*
Student 2
- Add another student
Last Name*
First Name*
MI
Gender/ Preferred Pronoun
Date of Birth*
MM slash DD slash YYYY
Age (as of Sept. 2022)
Hebrew Name
Address (if different)*
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 2021)
For Chai 385 8th Graders, what day(s)?
- Tuesday
- Sunday
- Both Tuesday & Sunday
Bar/ Bat Mitzvah date, if known
Attending Jewish Day or Overnight Camp in summer of 2021?
- Yes
- No
If so, where?
Previous Jewish Education: Has your child attended another synagogue or day school?
- Yes
- No
If so, where?
Medical Information
IMMUNIZATIONS*
I confirm that my child has been immunized in accordance with the MA Department of Public Health, and has been vaccinated for Covid-19, as eligible for their age.
- Yes
- No
IMMUNIZATIONS SIGNATURE*
MEDICATIONS*
Does your child take medications on a regular basis?
- Yes
- No
If so, what medications?
ALLERGIES*
Does your child have allergies on a regular basis? If so, please fill out the Allergy Information Form.
- Yes
- No
ALLERGY INFORMATION FORM
Student's Name
First Last
Grade
Allergy (1)*
Allergic To Reaction Treatment
Allergy (2)
Allergic To Reaction Treatment
Allergy (3)
Allergic To Reaction Treatment
I will provide an Epi-pen to the Religious School
- Yes
- No
My child carries an Epi-pen in their backpack
- Yes
- No
PARENT SIGNATURE*
Class Placement Policy Information
Would you like to provide input for your child's Class Placement?
- Yes
- No
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.
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
- No
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
- No
Please describe, and share any support plans in place:
Does your child have an IEP or 504 Plan?
- Yes
- No
If yes, please submit a current copy to the Religious School.
Upload IEP or 504 Plan here
Max. file size: 512 MB.
Does your child receive individual support services in the classroom at secular school?
- Yes
- No
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.*
- Yes
- No
Parent Signature/ Initials*
Student 3
- Add another student
Last Name*
First Name*
MI
Gender/ Preferred Pronoun
Date of Birth*
MM slash DD slash YYYY
Age (as of Sept. 2022)
Hebrew Name
Address (if different)*
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 2021)
For Chai 385 8th Graders, what day(s)?
- Tuesday
- Sunday
- Both Tuesday & Sunday
Bar/ Bat Mitzvah date, if known
Attending Jewish Day or Overnight Camp in summer of 2021?
- Yes
- No
If so, where?
Previous Jewish Education: Has your child attended another synagogue or day school?
- Yes
- No
If so, where?
Medical Information
IMMUNIZATIONS*
I confirm that my child has been immunized in accordance with the MA Department of Public Health, and has been vaccinated for Covid-19, as eligible for their age.
- Yes
- No
IMMUNIZATIONS SIGNATURE*
MEDICATIONS*
Does your child take medications on a regular basis?
- Yes
- No
If so, what medications?
ALLERGIES*
Does your child have allergies on a regular basis? If so, please fill out the Allergy Information Form.
- Yes
- No
ALLERGY INFORMATION FORM
Student's Name
First Last
Grade
Allergy (1)*
Allergic To Reaction Treatment
Allergy (2)
Allergic To Reaction Treatment
Allergy (3)
Allergic To Reaction Treatment
I will provide an Epi-pen to the Religious School
- Yes
- No
My child carries an Epi-pen in their backpack
- Yes
- No
PARENT SIGNATURE*
Class Placement Policy Information
Would you like to provide input for your child's Class Placement?
- Yes
- No
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.
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
- No
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
- No
Please describe, and share any support plans in place:
Does your child have an IEP or 504 Plan?
- Yes
- No
If yes, please submit a current copy to the Religious School.
Upload IEP or 504 Plan here
Max. file size: 512 MB.
Does your child receive individual support services in the classroom at secular school?
- Yes
- No
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.*
- Yes
- No
Parent Signature/ Initials*
Student 4
- Add another student
Last Name*
First Name*
MI
Gender/ Preferred Pronoun
Date of Birth*
MM slash DD slash YYYY
Age (as of Sept. 2022)
Hebrew Name
Address (if different)*
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 2021)
For Chai 385 8th Graders, what day(s)?
- Tuesday
- Sunday
- Both Tuesday & Sunday
Bar/ Bat Mitzvah date, if known
Attending Jewish Day or Overnight Camp in summer of 2021?
- Yes
- No
If so, where?
Previous Jewish Education: Has your child attended another synagogue or day school?
- Yes
- No
If so, where?
Medical Information
IMMUNIZATIONS*
I confirm that my child has been immunized in accordance with the MA Department of Public Health, and has been vaccinated for Covid-19, as eligible for their age.
- Yes
- No
IMMUNIZATIONS SIGNATURE*
MEDICATIONS*
Does your child take medications on a regular basis?
- Yes
- No
If so, what medications?
ALLERGIES*
Does your child have allergies on a regular basis? If so, please fill out the Allergy Information Form.
- Yes
- No
ALLERGY INFORMATION FORM
Student's Name
First Last
Grade
Allergy (1)*
Allergic To Reaction Treatment
Allergy (2)
Allergic To Reaction Treatment
Allergy (3)
Allergic To Reaction Treatment
I will provide an Epi-pen to the Religious School
- Yes
- No
My child carries an Epi-pen in their backpack
- Yes
- No
PARENT SIGNATURE*
Class Placement Policy Information
Would you like to provide input for your child's Class Placement?
- Yes
- No
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.
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
- No
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
- No
Please describe, and share any support plans in place:
Does your child have an IEP or 504 Plan?
- Yes
- No
If yes, please submit a current copy to the Religious School.
Upload IEP or 504 Plan here
Max. file size: 512 MB.
Does your child receive individual support services in the classroom at secular school?
- Yes
- No
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.*
- Yes
- No
Parent Signature/ Initials*
SIBLINGS
Name Age Grade
Emergency Information
IN CASE OF EMERGENCY:*
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
- No
If possible, I prefer that my child/children be taken to the following hospital:
If possible, please contact the following physician:
Physician Phone
Health Insurance Provider/Policy #:
Emergency Contacts (other than parents)
Emergency Contact Name [1]*
Phone [1]*
Relationship to Child [1]*
Emergency Contact Name [2]
Phone [2]
Relationship to Child [2]
PARENTAL PHOTO/FIELD-TRIP AUTHORIZATION – Agreement for 2021/2022 School year:
Images*
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
- No
Field Trips*
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
- No
Other Information
Financial Assistance: Do you anticipate needing tuition scholarship assistance?*
- Yes
- No
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 Mady Donoff, President (mdonoff@templeemanuel.com). You will be contacted confidentially.
Signature*
Date*
MM slash DD slash YYYY

Name	Age	Grade

Religious School 2021-22/5782 Enrollment

Religious School Enrollment Form

Parent Information - Parent 1

Parent Information - Parent 2

Student's Information

Medical Information

ALLERGY INFORMATION FORM

Class Placement Policy Information

Learning Support Information

Medical Information

ALLERGY INFORMATION FORM

Class Placement Policy Information

Learning Support Information

Medical Information

ALLERGY INFORMATION FORM

Class Placement Policy Information

Learning Support Information

Medical Information

ALLERGY INFORMATION FORM

Class Placement Policy Information

Learning Support Information

Emergency Information

Emergency Contacts (other than parents)

PARENTAL PHOTO/FIELD-TRIP AUTHORIZATION – Agreement for 2021/2022 School year:

Other Information