Kol Dorot Religious School Enrollment 5780 - Form

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Instructions for Kol Dorot Religious School Enrollment Form:

Fill out the Enrollment section for up to two children. If you are enrolling 3 or more students, you will have to complete and submit this form twice.

If you are having difficulty with the form, please contact the office at 201-664-7422.

FAMILY INFORMATION

* Parent/Guardian (1) Name

Parent/Guardian (2) Name

* Parent/Guardian (1) Best Phone Number

Parent/Guardian (2) Best Phone Number

* Parent/Guardian (1) Email

Parent/Guardian (2) Email

Parent/Guardian (1) Street

Parent/Guardian (2) Street (If Different)

Parent/Guardian (1) City

Parent/Guardian (2) City (If Different)

Parent/Guardian (1) State

Parent/Guardian (2) State (If Different)

Parent/Guardian (1) Zip

Parent/Guardian (2) Zip (If Different)

Additional Parent/Guardian Custody Information

Emergency Contact Name

Emergency Contact Cell Phone

Student (1) First Name

Student (2) First Name

Student (1) Last Name

Student (2) Last Name

Enrollment Grade - Student (1)

Enrollment Grade - Student (2)

School Track (1) for Grades 3-7 (See flyer)

My child is in Grades K-2Hebrew Sun 9-11 am / Jewish Life - Tues 4-6 pmHebrew Sun 9-11 am / Jewish Life - Peirot Flex Track

School Track (2) for Grades 3-7 (See flyer)

My child is in Grades K-2Hebrew Sun 9-11 am / Jewish Life - Tues 4-6 pmHebrew Sun 9-11 am / Jewish Life - Peirot Flex Track

Student (1) Hebrew Name

Student (2) Hebrew Name

Student (1) Birthday

Student (2) Birthday

ALLERGY INFORMATION

Information for Student (1)

Information for Student (2)

Does Student (1) have any allergies?

Yes. My child has allergies.No. My child has no allergies.

Does Student (2) have any allergies?

Yes. My child has allergies.No. My child has no allergies.

List all food allergies student (1):

List all food allergies student (2):

List all other allergies student (1):

List all other allergies student (2):

Does student (1) have an EpiPen?

YesNo

All EpiPens at TBO must have photo ID attached.

Does student (2) have an EpiPen?

YesNo

All EpiPens at TBO must have photo ID attached.

If yes, student (1) EpiPen location:

Special carrier on his/her personIn his/her backpackIn the classroom with the teacherOther

If yes, student (2) EpiPen location:

Special carrier on his/her personIn his/her backpackIn the classroom with the teacherOther

If other, please explain - student (1).

If other, please explain - student (2).

SCHOOL INFORMATION

Does student (1) have an Individual Education Plan (IEP) 504 or Building Level Plan of any sort in public/private school?

YesNo

If yes, we will contact you to discuss the appropriate accommodations for your child.

Does student (2) have an Individual Education Plan (IEP) 504 or Building Level Plan of any sort in public/private school?

YesNo

If yes, we will contact you to discuss the appropriate accommodations for your child.

Does student (1) have any medical conditions or learning differences or take any medication that could affect their religious school experience?

YesNo

Does student (2) have any medical conditions or learning differences or take any medication that could affect their religious school experience?

YesNo

If yes, please provide details for student (1).

If yes, please provide details for student (2).

Is there anything else you would like to share about student (1)?

Is there anything else you would like to share about student (2)?

FAMILY PUBLICITY PERMISSION

Yes I give my permission.No I do not give my permission.

By clicking yes - you are agreeing that Student's photograph, name, art, written work, voice, or verbal statements may appear in Kol Dorot publicity or publications.

FAMILY MEDICAL EMERGENCY INFORMATION

Doctor's Name:

Doctor's Phone Number:

Insurance Company

Policy ID Number

Group Number

I hereby give permission for my child(ren) to be taken off Temple grounds for the purpose of medical attention in the event that I cannot be contacted in an emergency. I authorize and designate the Rabbi or Religious School Director as my representative in the event of a medical emergency concerning my child.

Yes I give my permission.No I do not give my permission.

TUITION AND FEES

Choose one below for each student enrolling. Payment options (including the ability to divide this payment over up to 12 months) will be given on the following page.

Pay in Full Option - Please enroll my child in:

K-2 pay in full - $950Grade 3 pay in full - $1450Grade 4 pay in full - $1450 + $45 Activity FeeGrade 5 pay in full - $1450 + $40 Activity FeeGrade 6 pay in full - $1450 + $120 Activity FeeGrade 7 pay in full - $1450 + $80 Activity

Deposit Only Option - Please enroll my child in:

Special Financial Arrangement

Special Financial ArrangementIf you have made a financial arrangement with Kol Dorot that is different from the options above, please click here to register without being billed through this form. If you would like to speak to someone about a special financial arrangement, please contact the Kol Dorot office at (201) 664-7422 before submitting this form.

Sibling Discount

Sibling DiscountIf you are enrolling more than one student, check here for a $250 sibling discount.

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