Beth Israel Religious School Registration

Confidential Information Form 2009 - 10

Please photocopy and fill out one form PER CHILD

Please fill out this form (one form per child) to help us meet your child’s unique needs. This form will be removed from the rest of the registration information and kept in a secure file. This form is not mandatory but it will help us to achieve the best possible learning environment for your child.

Student’s Name ______________________________________________

Student’s Grade ___________

I choose not to fill out this form. ­­­­­­____________

I give permission for my child’s Religious School/Hebrew School teacher to see this form. ____ yes ____ no

Please describe your child’s past experience in Religious/Hebrew School.

What are your goals for your child’s religious education this year?

Does your child have any health problems of which we should be aware? Please explain.

Does your child have any learning challenges of which we should be aware? Please explain.

Is your child in any enrichment/special needs programs in his/her school?

Is your child on any medication (such as Ritalin, allergy medication, etc.)? Please explain.

Are there any special family situations of which we should be aware?

Is there any thing else we should know in order to better meet your child’s needs?

If you would like to tell me a little more about your child, please give the best time to call and I would be happy to contact you.

Your Name  ____________________________ Phone Number  ______________

Best time to call _____

Please note: while you are not required to fill out this form, we will be better able to meet your child’s needs if we know of any special requirements he or she may have.

Beth Israel Religious School Registration Form 2009-2010

Mother’s Name ______________________________ Business Phone ____________ Cell/Beeper _____________

Father’s Name _______________________________ Business Phone ____________ Cell/Beeper _____________

Address (mailing) __________________________________________________________________________________________

Home Phone ____________________   Best e-mail address for sending school information _________________________________________

With whom do the children live?           ___ both parents           ___ mother       ____ father        ____ other ___________________

If parents are separated/divorced:

To whom should we send school information?   _____ both parents ____ mother ____ father   _____ other ______________________

Address 2 ___________________________________________________________________________________________

Home phone 2 ____________________   Email 2 _____________________________________________

Children’s Physician ___________________________________________________ Phone Number ____________

Name of Medical Insurance Company ______________________________________ Policy Number ______________

Authorized person(s) to pick up your child(ren) from Religious School _________________________________________

People to contact in the event of an emergency (after child’s parents):

Name ___________________________________________ Relationship _______________ Phone ____________

Name ___________________________________________ Relationship _______________ Phone ____________