Shorashim Hebrew School Fall 2024 Registration - Form - Highland Park Conservative Temple

Shorashim Hebrew School at HPCT-CAE

Fall Session 2024:
Sundays 9:45 - 11:45 AM
Sept. 8th - Dec. 15th
No classes on Oct. 6th, Oct. 20th, Dec 1st

Registration Form

* How many children are you registering?

Information for Parent/Guardian 1:

* First Name

* Last Name

* Relationship to child(ren):

* Email Address:

* Cell Phone:

Information for Parent/Guardian 2:

First Name

Last Name

Relationship to child(ren):

Email Address:

Cell Phone:

Primary Address:

* Street Address

* City

* State

* Zip

Additional Emergency Contacts

Please enter the names of two emergency contacts who are not parents/guardians of the child(ren) registering.

* Name of Primary Emergency Contact

* Phone Number of Primary Emergency Contact

* Relationship of Primary Emergency Contact to Child(ren)

For example: Grandparent, Cousin, Friend

* Name of Secondary Emergency Contact

* Phone Number of Secondary Emergency Contact

* Relationship of Secondary Emergency Contact to Child(ren)

For example: Grandparent, Cousin, Friend

Consent for Emergency Medical Treatment of Child(ren)

* Emergency Treatment Consent

Yes, I give my consent for emergency medical treatment of my child(ren) as outlined below.No, I do not give my consent for emergency medical treatment of my child(ren).

Emergency Medical Release: In case of emergency, I understand that every effort will be made to contact the parents, guardians, or emergency contacts. In the event that they cannot be reached, I hereby give my consent for the administration of any treatment deemed necessary by emergency medical professionals to secure treatment for my child and other actions taken to secure proper treatment for my child, including the transfer of my child to any hospital reasonably accessible.

* Name of Parent/Legal Guardian Submitting 'Consent for Emergency Medical Treatment':

Please write the name of the parent/guardian filling out this form.

Photographic Image Permission:

Shorashim Hebrew School at HPCT-CAE, its employees, or agents have the right to take photographs, videotape, or digital recordings ("Images") of me or my child(ren) and to use them in the following ways:
1. Sharing photos of my child(ren) with faces visible in internal communication only, including our school newsletter and emails that are sent to registered families only.
2. Sharing photos of my child(ren) which do not show children's faces in external communication, including photos on our website or on social media. The photos will not include any names or personal identifiers.

This is important in order for us to share and communicate the educational activities our program has to offer.

If you have concerns or special considerations, please contact us directly by email at ShorashimHebrewSchool@gmail.com

* Photographic Consent

Yes, I do hereby consent and agree with the statement above and allow the use of images of myself or my child in the media.No, I do not consent to the use of images of myself or my child(ren) in the media.I do hereby release to Shorashim Hebrew School at HPCT-CAE, its agents, and employees all rights to exhibit this work in print and electronic form publicly or privately as detailed above. I wave any rights, claims, or interest I may have to control the use of my image in whatever media used.

CHILD 1 INFORMATION

* First Name

* Last Name

* Date of Birth

Preferred Name/Nickname:

Hebrew Name

If applicable

* Name of Child's School:

* Grade Entering in Fall 2024:

Allergy Information, Medical Considerations, and Support Needs:

If your child has a food allergy, we require that an unopened EpiPen pack along with instructions and contact phone numbers be provided in a plastic zip-lock bag, labeled with your child's name.

If there is a chance that your child will need medication, such as an inhaler for asthma, during school hours, please provide an unopened package of the medication labeled with your child's name, instructions and contact phone numbers in a plastic zip-lock bag.

Please let us know if your child has any other support needs so that we can work together to meet them.

Primary Physician Name

Primary Physician Phone Number

CHILD 2 INFORMATION

* First Name

* Last Name

* Date of Birth

Preferred Name/Nickname:

Hebrew Name

If applicable

* Name of Child's School:

* Grade Entering in Fall 2024:

Allergy Information, Medical Considerations, and Support Needs:

Primary Physician Name

Primary Physician Phone Number

CHILD 3 INFORMATION

First Name

Last Name

Date of Birth

Preferred Name/Nickname:

Hebrew Name

If applicable

* Name of Child's School:

* Grade Entering in Fall 2024:

Allergy Information, Medical Considerations, and Support Needs:

Primary Physician Name

Primary Physician Phone Number

CHILD 4 INFORMATION

* First Name

Last Name

Date of Birth:

Preferred Name/Nickname:

Hebrew Name

If applicable

* Name of Child's School:

* Grade Entering in Fall 2024:

Allergy Information, Medical Considerations, and Support Needs:

Primary Physician Name

Primary Physician Phone Number

* Are you a current member of HPCT-CAE?

Please Select OneNon-MemberMember

If you are enrolling a baby/toddler in addition to older siblings, please enter the information for your baby/toddler first, to optimize the sibling discount.

* Enrollment Type for Child 1:

Enrollment Type for Child 2:

Enrollment Type for Child 3:

Enrollment Type for Child 4:

* Enrollment Type for Child 1: (Member Rate)

Enrollment Type for Child 2: (Member Rate)

Enrollment Type for Child 3: (Member Rate)

Enrollment Type for Child 4: (Member Rate)

Total Tuition for all children:

The above amount is the total enrollment fee for Shorashim Hebrew School for all children registered.

I will pay my tuition as follows:

Please Select OneI will pay by credit card. Make a payment after selecting submit below.I will pay by check (payable to Shorashim Hebrew School. Mail to: 201 S 3rd Ave., Highland Park, NJ 08904) Select "Bill to Account" on the payment page.My family would benefit from a scholarship. Select "Bill to Account" on the payment page.

Please note that finances will never stand in the way of your child's education at Shorashim Hebrew School at HPCT-CAE. If you would benefit from or would like to discuss a scholarship, please let us know by checking the Scholarship option above and someone from our office will be in touch.

For any other questions or assistance, please email us at ShorashimHebrewSchool@gmail.com.

Thank you!