2022-23 Religous School Form

Welcome!

Thank you for enrolling your child(ren) in the Temple Beth David Religious School. (Please note that if you want to set up a payment plan or pay using a payment method linked to your account, you will need to log in before filling out this form.)

Adult Member Information

* First Name

Middle Name

* Last Name

* Phone Number

* Email

Religious School Registration

2022-23 School Tuition and Fees:

Pre-K/K - $485
1st Grade - $570
2nd Grade - $635
3rd Grade - $760
4th Grade - $845
5th Grade - $875 + B'nai Mitzvah Assessment of $150
6th Grade - $915 + B'nai Mitzvah Assessment of $250
7th Grade - $1095 + B'nai Mitzvah Assessment of $250

* How many children are being enrolled in Temple Beth David's Religious School Program?

* Name of Student 1

* Name of Student 2

* Name of Student 3

* Name of Student 4

Hebrew Name of Student 1

Hebrew Name of Student 2

Hebrew Name of Student 3

Hebrew Name of Student 4

Name of secular school Student 1 is entering in the fall

Name of secular school Student 2 is entering in the fall

Name of secular school Student 3 is entering in the fall

Name of secular school Student 4 is entering in the fall

Secular school grade entering in the fall - Student 1

Secular school grade entering in the fall - Student 2

Secular school grade entering in the fall - Student 3

Secular school grade entering in the fall - Student 4

* I grant permission for photos of my child(ren) to be used in promotional material for TBD programs and for use on the Temple website and social media.

Please Select OneYesNo

EDUCATIONAL CONSIDERATIONS

In the text box(es) below, please note if your child(ren) receive(s) any education services, such as IEP, Adaptive Equipment, Special Education, Outside Tutoring, Physical / Occupational Therapy, Behavioral Resource, Gifted/Talented, etc.

Student 1

Student 2

Student 3

Student 4

Student 1 - What are your child's strengths? (Highlight all areas in which your child does well, including educational and social.)

Student 2 - What are your child's strengths? (Highlight all areas in which your child does well, including educational and social.)

Student 3 - What are your child's strengths? (Highlight all areas in which your child does well, including educational and social.)

Student 4 - What are your child's strengths? (Highlight all areas in which your child does well, including educational and social.)

Student 1 - What are your child's greatest challenges? (List areas in which your child has the greatest difficulties.

Student 2 - What are your child's greatest challenges? (List areas in which your child has the greatest difficulties.

Student 3 - What are your child's greatest challenges? (List areas in which your child has the greatest difficulties.

Student 4 - What are your child's greatest challenges? (List areas in which your child has the greatest difficulties.

DIAGNOSES OR ASSESSMENTS

In the text box(es) below, please note if your child(ren) is/are diagnosed as having, or is being assessed for any of the following: ADHD, Anxiety, Autism Spectrum Disorder, Conduct/Oppositional Disorder, Developmental/Cognitive Delay, Depression, Emotional/Behavioral Disorder, Hearing Disorder, Learning Disability, Obsessive Compulsive Disorder (OCD), Speech/Language Disability, Physical Disability, Cerebral Palsy, Tourette Syndrome, Visual Impairment, Other.

Student 1

Student 2

Student 3

Student 4

MEDICAL INFORMATION

* In case of medical emergency, if parents or emergency contact cannot be reached, Religious School staff has my permission to seek emergency medical care for my child.

Please Select OneYesNo

Pediatrician's name and phone number

Insurance Company

Insurance Policy Number

Please list any serious allergies Student 1 has including food allergies, bee stings, etc. and what action must be taken in the event of exposure to an allergen.

Please list any serious allergies Student 2 has including food allergies, bee stings, etc. and what action must be taken in the event of exposure to an allergen.

Please list any serious allergies Student 3 has including food allergies, bee stings, etc. and what action must be taken in the event of exposure to an allergen.

Please list any serious allergies Student 4 has including food allergies, bee stings, etc. and what action must be taken in the event of exposure to an allergen.

Please list any medications Student 1 is taking.

Please list any medications Student 2 is taking.

Please list any medications Student 3 is taking.

Please list any medications Student 4 is taking.

* Who is allowed to pick up your child(ren) from school?

Please enter one or more names of people you authorize to pick up your child(ren) after school.

EMERGENCY CONTACT INFORMATION

Please list two people who we may contact in the event we are unable to reach a parent in an emergency.

* Emergency Contact 1
First Name

* Emergency Contact 1
Last Name

* Emergency Contact 1 Relationship

e.g. grandparent, aunt, family friend, etc.

* Emergency Contact 1 Phone

* Emergency Contact 2
First Name

* Emergency Contact 2 Last Name

* Emergency Contact 2 Relationship

e.g. grandparent, aunt, family friend, etc.

* Emergency Contact 2 Phone

TOTAL:

Total Religious School Tuition

MEMBERSHIP SUMMARY

* I agree to fulfill my financial obligations as indicated above.

I agree to fulfill my financial obligations as indicated above.

* First and Last Name

* Date

ADMINISTRATION

On the next page you will be presented with payment options.

You may make your payment by ACH/eCheck, credit card, or choose to have it billed to your account so that you may make other arrangements, such as paying by check.

If you choose to pay by ACH/eCheck or credit card, you may also specify if you wish to pay in full via a single payment, or via 2-10 monthly installments, right on the payment page. If you choose to pay now via a single payment, your account will be charged on 07/01/2022 or the date you made your payment, whichever is later.

IMPORTANT NOTE: We strongly encourage you to select either ACH/eCheck or a credit card for your payments. By using one of these methods it improves the temple's ability to serve our members and reduces manual input.

**TO PAY BY CHECK, PLEASE READ BELOW**
If you wish to pay using a check or will be transferring stock, on the next page please select Pay this amount [Once Now], then select the default payment method Bill To My Account. (You must be logged in to see this option so the system knows which account to bill. Bill to My Account will be the default payment method and shaded as shown below if you are logged in.) Even though you are required to select [Once Now], you can submit payments as you wish (monthly, quarterly, etc.).

Please click the 'Save and Continue' button below.

Adult Member Information

2022-23 School Tuition and Fees:

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