Merkaz Limud & JTL Registration Form 21-22

Merkaz Limud & JTL Registration 21-22

* Today's Date

Parent Information

Parent 1: First Name

Parent 1: Last Name

Parent 1: Work Phone

Parent 1: Cell Phone

Parent 1: Email

Parent 1: Address, City, State, Zip

Parent 2: First Name

Parent 2: Last Name

Parent 2: Work Phone

Parent 2: Cell Phone

Parent 2: Email

Parent 2: Address, City, State, Zip

Child(ren) Resides with:

Both ParentsMotherFather

Please choose primary contact if child(ren) does not live with both parents.

MotherFather

If child does not live with both parents please provide other parent's information if not listed above. Include Parent Name, Address, Work Phone and Cell Phone.

Grandparent Information

First and Last Name

Address, City, State, Zip code

Phone Number

First and Last Name

Address, City, State, Zip code

Phone Number

Student #1 Information

Student #1 First Name

Student #1 Last Name

Student #1 Gender

MaleFemale

Student #1: Hebrew Name

Student #1: Date of Birth

Student #1: Age

Student #1: School Attending

Student #1: Grade Level as of September 2021

Student #1: Bar/Bat Mitzvah Date (if applicable)

Student #1: Student E-mail

The following information will be held in the strictest of confidence. You are welcome to make an appointment with Noemi Gozlan to discuss any item at length. If you desire such an appointment, please email religiousschool@templebethemet.org

Student #1: Does your child receive or has he/she received any of the following services?

Psychological

YesNoNo Longer

Speech & Language

YesNoNo Longer

Physical Therapy

YesNoNo Longer

Occupational Therapy

YesNoNo Longer

Student #1: Has your child had any psychological/neurological evaluations and/or testing? If so please submit any relevant test results and recommendations.

YesNo

Student #1: Does your child receive any medication? Yes or No. If yes, please explain.

Student #1: Does your child have any allergies to food, medication, insects, etc? Yes or No. If yes, please explain.

Student #1: Is there any additional information concerning your child about which the school should be aware? (physical/emotional, development, family life, custodial arrangements, etc.) Yes or No. If yes, please explain.

Student #2 Information

Student #2 First Name

Student #2 Last Name

Student #2 Gender

MaleFemale

Student #2: Hebrew Name

Student #2: Date of Birth

Student #2: Age

Student #2: School Attending

Student #2: Grade Level as of September 2021

Student #2: Bar/Bat Mitzvah Date (if applicable)

Student #2: Student E-mail

Student #2: Does your child receive or has he/she received any of the following services?

Psychological

YesNoNo Longer

Speech & Language

YesNoNo Longer

Physical Therapy

YesNoNo Longer

Occupational Therapy

YesNoNo Longer

Student #2: Has your child had any psychological/neurological evaluations and/or testing? If so please submit any relevant test results and recommendations.

YesNo

Student #2: Does your child receive any medication? Yes or No. If yes, please explain.

Student #2: Does your child have any allergies to food, medication, insects, etc? Yes or No. If yes, please explain.

Student #2: Is there any additional information concerning your child about which the school should be aware? (physical/emotional, development, family life, custodial arrangements, etc.) Yes or No. If yes, please explain.

Student #3 Information

Student #3 First Name

Student #3 Last Name

Student #3 Gender

MaleFemale

Student #3: Hebrew Name

Student #3: Date of Birth

Student #3: Age

Student #3: School Attending

Student #3: Grade Level as of September 2021

Student #3: Bar/Bat Mitzvah Date (if applicable)

Student #3: Student E-mail

Student #3: Does your child receive or has he/she received any of the following services?

Psychological

YesNoNo Longer

Speech & Language

YesNoNo Longer

Physical Therapy

YesNoNo Longer

Occupational Therapy

YesNoNo Longer

Student #3: Has your child had any psychological/neurological evaluations and/or testing? If so please submit any relevant test results and recommendations.

YesNo

Student #3: Does your child receive any medication? Yes or No. If yes, please explain.

Student #3: Does your child have any allergies to food, medication, insects, etc? Yes or No. If yes, please explain.

Student #3: Is there any additional information concerning your child about which the school should be aware? (physical/emotional, development, family life, custodial arrangements, etc.) Yes or No. If yes, please explain.

Emergency Contacts

Parents are always contacted first, however, in case of illness, accident or injury please list additional people below who can be contacted. Please list persons full name, phone number and relationship to your child(ren).

Health Insurance Information

Include the following information:
Name of Insured
Name of Insurance Company
Policy #

Child(ren) Doctor's Information

Include the following information:
Doctor Name & Phone Number

Authorization for Emergency Medical - Surgical Treatment

It is the firm hope that the authorization granted on this form will never have to be used. For the safety of your child, however, sound medical practice calls for such authorization. In emergency situations where the parent of the child cannot be contacted immediately, this form may become extremely important. The authorization granted by this form will be used only where absolutely necessary and only after every attempt has been made to contact the parents. Doctors and hospitals refuse to give any treatment, regardless of how minor, unless they have authorization from the parents.
IN THE EVENT I CANNOT BE REACHED, I HEREBY GRANT PERMISSION TO THE PHYSICIAN OR HOSPITAL SELECTED BY THE TEMPLE TO HOSPITALIZE, SECURE PROPER TREATMENT, ORDER INJECTION, ANESTHESIA, OR PERFORM SURGERY FOR MY CHILD.

Please electronically sign your name.

Class Schedule Preference
The safety of our families and staff are our number one priority. Families will need to be flexible during these uncertain times. Please keep an open mind when choosing your class preference. Based on current and changing CDC guidelines, TBE guidelines and health concerns, we may have to change schedules.

PreK - 6th Grade Options

Option A: Sundays (on-site) 9:00 am-12:30 pm (PreK-6th grade)
Option B: Mondays (on-site) 4:00-7:30 pm (PreK-5th grade)
Option C: Mondays (on-site) 4:15-7:30 pm (6th grade)

7th Grade Options
*Please note, every 7th grade student, regardless of their Bar/Bat Mitzvah date, is required to be registered and attend a 7th grade Judaica & Hebrew class.

Option D: Sundays (on-site) 9:00-11:30 am (includes Hebrew & Judaica classes)
Option E: Mondays (on-site) 5:00-8:00 pm (includes Hebrew & Judaica classes, 30 minute dinner break)

8th, 9th, 10th Grade Confirmation Options

Option F: Mondays (on-site) 6:30-8:00 pm

STUDENT CLASS CHOICES:

Class Choice Student #1

Class Choice Student #2

Class Choice Student #3

Photo Permission is granted to use any photographs and videos of my child to be taken during Merkaz Limud/JTL for promotional purposes in all media including Temple Beth Emet websites and social media (no names will be used with pictures).

YesNo

I/we give TBE permission to contact us via electronic media such as email, text messages, cell calls and automatic phone messages.

YesNo

TBE Membership & Merkaz Limud/JTL Fee Schedule 2021-2022

Annual Membership Commitment Categories

Family Membership - $2100 (2 adults with at least 1 child in K - 12^th grade)
Single Parent Membership - $1600 (1 adult with at least 1 child in Kindergarten - 12^th grade)
Special Dues Membership - If you need financial assistance for your dues please contact Laura Goodman, laura@templebethemet.org or 954-680-1882

Merkaz Limud & JTL FEES *(Fees are Per Child with exception of security fee which is per family)
*Pay with ACH, receive $25 discount from tuition only
*$300 Deposit required with each application and is non-refundable
(deposit covers registration fee and materials & program fee)

PreK - 2^nd grade
Tuition	$750
Registration Fee	$50
Materials & Program Fee	$250
Security Fee	$250

3^rd - 7^th grade
Tuition	$960
Registration Fee	$50
Materials & Program Fee	$250
Security Fee	$250

8^th- 10^th grade
Tuition	$690
Registration Fee	$50
Materials & Program Fee	$250
Security Fee	$250
Confirmation Package (10th grade Only) Oneg Shabbat, Kiddush, Flowers, setup, etc.	$180

Registration & Financial Policy

We will have a health screening process in place as children and staff enter our campus.
Parents will not be permitted to come into the classrooms.
Merkaz Limud/JTL classes will be limited in size.
Membership is required to be enrolled in Merkaz Limud/JTL.
A NON-REFUNDABLE Deposit of $300 which includes (Registration Fee & Material Program fee) is due upon enrollment of each student.
There is a $250 Security Service Fee per family.
All Membership and Merkaz Limud/JTL fees must be paid in full by April 1, 2022.

Payment Agreement
*Registration will be processed ONLY upon full completion of Payment Agreement.
Deposit is due upon receipt of registration form.

* Please electronically sign - I understand and accept the above Registration & Financial Policy.

Select Membership Category

Family Membership - $2100Single Parent Membership - $1600Special Dues Membership (to apply for financial assistance please submit TBE Financial Aid form along with your 2020 taxes).

Select Form of Payment

Post Dated ChecksACH WithdrawlsCredit Card

Please choose date to charge for your membership & tuition payments. (1st or 15th of the month).

Select Payment Options

4 equal installments3 equal installments2 equal installments1 equal installment

ACH Payment Information (No changes may be made within 10 business days of payment)

Email for Notifications

Name on Check

Routing Number

Account Number

Billing Address if different from above

Credit Card Payment Information

Name on Card

Card Number

Expiration Date

Security Code

Billing Address if different from above

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