Temple Beth Tikvah: Families

Family Information

Family Last Name

Phone

Address

City

Zip

Student Information

Student #1

Last Name

First Name

Hebrew Name

Birth Date--

Secular School Name

Grade

Will your child participate in choir?

Does your student have any hearing problems?

Does the student wear glasses?

Reading Level

Does your child have any dietary restrictions or allergies?

What medication does your child take and how frequently (times of the day)

What special secular class programs is your child in? (ie: GATE, RSP)

Does your child play any instruments?

What scouting program is your child in?

Do you want them to work towards a religious award?

Please provide any additional information (ie talents, interests, home situation, etc)

Student #2 [Click to expand]

Last Name

First Name

Hebrew Name

Birth Date--

Secular School Name

Grade

Will your child participate in choir?

Does your student have any hearing problems?

Does the student wear glasses?

Reading Level

Does your child have any dietary restrictions or allergies?

What medication does your child take and how frequently (times of the day)

What special secular class programs is your child in? (ie: GATE, RSP)

Does your child play any instruments?

What scouting program is your child in?

Do you want them to work towards a religious award?

Please provide any additional information (ie talents, interests, home situation, etc)

Student #3 [Click to expand]

Last Name

First Name

Hebrew Name

Birth Date--

Secular School Name

Grade

Will your child participate in choir?

Does your student have any hearing problems?

Does the student wear glasses?

Reading Level

Does your child have any dietary restrictions or allergies?

What medication does your child take and how frequently (times of the day)

What special secular class programs is your child in? (ie: GATE, RSP)

Does your child play any instruments?

What scouting program is your child in?

Do you want them to work towards a religious award?

Please provide any additional information (ie talents, interests, home situation, etc)

Student #4 [Click to expand]

Last Name

First Name

Hebrew Name

Birth Date--

Secular School Name

Grade

Will your child participate in choir?

Does your student have any hearing problems?

Does the student wear glasses?

Reading Level

Does your child have any dietary restrictions or allergies?

What medication does your child take and how frequently (times of the day)

What special secular class programs is your child in? (ie: GATE, RSP)

Does your child play any instruments?

What scouting program is your child in?

Do you want them to work towards a religious award?

Please provide any additional information (ie talents, interests, home situation, etc)

Parent / Gaurdian Information

Parent #1

Name

Cellphone

Address (if different)

City

Zipcode

Occupation

Phone

Send Communications to both Addresses?

May we call you at work?

Parent #2

Name

Cellphone

Address (if different)

City

Zipcode

Occupation

Phone

Send Communications to both Addresses?

May we call you at work?

Photograph Release

TBT has permission to take photos of my child for publicity purposes in various media. I understand no commercial use will be made of these photos.

Please enter your full name to sign this agreement

Emergency

Someone to Contact when you cannot be reached

Name

Address

Phone

Relationship to Student

Out of State contact in case of emergency

Name

Address

Phone

Relationship to Student

TBT or its representative has my permission to secure emergency aid for my child, named above, in case i cannot be reached.

Preferred Doctor

Doctor's Phone

Preferred Hospital

Please enter your full name as signature to the above agreement.

Temple Beth Tikvah

Step 1 of 3: Student Registration

Family Information

Student Information

Parent / Gaurdian Information

Photograph Release

Emergency