INSTRUCTIONS:

*Please be sure to complete the following 4 SECTIONS: Children's Information, Emergency Contact, Transportation Assistance, & Parent Volunteer.

*The "Tuition" section is only for new members joining after August 1, 2021. Skip this section if you have been a member of Temple Sinai prior to this date, and ignore the $0 total you will see on your confirmation page.

*If nothing happens when you press "Submit" at the end, it means that there is a REQUIRED FIELD somewhere that still needs completing. Incomplete sections should turn pink, allowing you to more easily find them and ensure that all required fields inside them are complete.

*If, when done, you see a blank WHITE PAGE after hitting "Submit", simply scroll up to view your registration confirmation message!

Questions? Please email Jason Marx (jason@temple-sinai.net) with a description of the issue. He will be happy to assist you. :)

Name of Parent 1

Last Name, First Name

Cell Phone

(xxx) xxx-xxxx

Residence Phone

(xxx) xxx-xxxx

E-mail Address

Name of Parent 2

Last Name, First Name

Cell Phone

(xxx) xxx-xxxx

Residence Phone

(xxx) xxx-xxxx

Email Address

Please List all the children you are enrolling at Temple Sinai

* Child 1 Name

Last Name, First Name

* Birth Date - Child 1

MM/DD/YY

* School Grade - Child 1

* Name of School - Child 1

Child 2 Name

Last Name, First Name

Birth Date - Child 2

MM/DD/YY

School Grade - Child 2

Name of School - Child 2

Child 3 Name

Last Name, First Name

Birth Date - Child 3

MM/DD/YY

School Grade - Child 3

Name of School - Child 3

Describe any family arrangement which might affect your child’s (children’s) attendance:

Personal Contact Request

If you would prefer to discuss any of the above personally and confidentially with the Director of Education or the Rabbi, please indicate your wish for a call by checking this box.

2) Tuition Information (NEW MEMBERS ONLY)

ONLY FILL OUT THIS SECTION IF YOU ARE A NEW MEMBER JOINING AFTER AUGUST 1, 2021. If you have any questions please reach out to Susan Hain (susanhain@hotmail.com).

Please type in the number of children you are registering per grade

My Family and Me (Temple Members)

A wonderful once-a-month program for 3 to 4 years and parents or other adult family members

My Family and Me (Non-Member Family)

Kindergarten (free)

Grades 1 - 3

I am registering more than 1 child for Religious School and the younger one is in Grades 1-3

Grades 4 - 7

I am registering more than 1 child for Religious School and the younger one is in Grades 4-7

Grades 7 - B'nei Mitzvah

Grades 8 - 10 Metivta

I am registering more than 1 child for Metivta and would like the multi-child discount.

If tuition owed, will you pay by check?

Please make checks payable to TEMPLE SINAI OF GLENDALE.

3) Emergency Contact Information

Student 1

* Name - Student 1

Last Name, First Name

Known Allergies and Medical Conditions - Student 1

* Physician Name - Student 1

* Physician Phone Number - Student 1

(xxx) xxx-xxxx

If the school cannot contact a parent, name a relative or friend who may be called upon if your child is ill.

Name and Contact Number - Student 1

Please list at least two Emergency Contacts

* Emergency Medical Treatment Authorization #1

I Agree

The School has my permission to authorize emergency medical treatment for my child. I understand that in a medical and/or disaster emergency situation the judgment of the school authorities will prevail. Anytime the above information must be changed, I will notify the school in writing.

Student 2

Name - Student 2

Last Name, First Name

Known Allergies and Medical Conditions - Student 2

Physician Name - Student 2

You can write "same" if identical to Student 1 information

Physician Phone Number - Student 2

You can write "same" if identical to Student 1 information

If the school cannot contact a parent, name a relative or friend who may be called upon if your child is ill.

Name and Contact Number - Student 2

You can write "same" if identical to Student 1 information

Emergency Medical Treatment Authorization #2

I Agree

Student 3

Name - Student 3

Last Name, First Name

Known Allergies and Medical Conditions- Student 3

Physician Name - Student 3

Physician Address, City, State, Zip - Student 3

You can write "same" if identical to Student 1 information

Physician Phone Number - Student 3

You can write "same" if identical to Student 1 information

If the school cannot contact a parent, name a relative or friend who may be called upon if your child is ill.

Name and Contact Number - Student 3

You can write "same" if identical to Student 1 information

Emergency Medical Treatment Authorization #3

I Agree

Agreement

In case of an EMERGENCY (bomb threat, earthquake, flooding, etc.) students will be kept at school or evacuated to a safe location until the parent or one of the below named people arrives. Students WILL NOT be released to any other adult unless written or verbal communication from the parent is obtained.

A doctor's prescription is required to administer ANY and ALL medication. This includes all brand and generic forms of non-prescription medications (e.g., Tylenol, Advil and Motrin). Should your child require medication during his / her attendance at School, the medication must be in the original container with current printed prescription instructions on the container.

I / We request that medication(s) be administered to our child if needed during and after an emergency by the School staff, faculty and / or clergy. It is understood that the School is not legally obligated to administer medication to my child, therefore, I agree to indemnify and hold the Temple Sinai faculty, staff and / or clergy and its agents harmless from any and all claims, demands, suits, challenges, or other action arising from the administration of medication or the provisions of special services as outlined in this document.

Emergency Pick Up Authorization

List up to 3 people who may pick up your child from School or in an emergency situation AND their phone numbers.

FOR NEW MEMBERS: I would like to pay the balance in installments with the first transaction processed today.

Account Details

Enter your name and e-mail address for your confirmation:

*E-mail

*First Name

*Last Name

Payment Information

Account

Online Fee:

Credit Card

Name on Card

Card Type

Card Number

Expiration Date

Card Verification Number

Address Line 1

City

State/Province

Zip

Comments

Increase the amount by 3% to cover credit card fees. Please select YES to increase your payment.

Total:

	My child(ren) are in a carpool WITH AN OPEN SPOT
	My child(ren) are in a FULL carpool
	My child(ren) will attend Sunday morning and I need help in finding a carpool or another transportation arrangement
	My child(ren) will attend Monday afternoon and I need help in finding a carpool or another transportation arrangement
	My child(ren) will attend Wednesday afternoon and I need help in finding a carpool or another transportation arrangement

	Parent Coordinator - By Myself
	Parent Coordinator - Working with another parent
	Cooking, art or other class projects needing adult supervision and assitance
	Purim Carnival set up
	Purim Carnival booth
	Purim Carnival tear down
	Purim Prize Room Assistance
	Model Seder preparation and set up
	Model Seder supervision and participation
	Model Seder clean up
	Speaking to the class/school - describe in comments below
	Field trip driver
	Substitute teacher
	Host a class Shabbat or Havdalah pot-luck in my home
	Other
	I cannot volunteer this year

School Registration Form 2021-2022