Religious School Registration for School Year 2023-2024

Religious School Registration for School Year 2023-2024:

Welcome! We are thankful you’re here, and looking forward to engaging your family in our religious school programming. Please note that our Pre-K class is open to the community, while all other grades (K-12) are for Fairmount Temple members only.

If you have questions about membership or want to learn more about our learning community, please contact Rabbi Elle Muhlbaum at [email protected] or 216-464-1330.

ONLINE REGISTRATION INSTRUCTIONS: Fill out Family information ONCE and then, fill out Student Information for EACH child being registered.

Please contact Elizabeth Kleckner at 216.464.5890 or [email protected] with questions.

Family Information

* Parent/Guardian 1

* Prefered Pronouns for Parent/Guardian 1

He / Him / His

She / Her / Hers

They / Them / Theirs

Other

Parent/Guardian 2

Prefered Pronouns for Parent/Guardian 2

He / Him / His

She / Her / Hers

They / Them / Theirs

Other

* Student(s) live with

Both Parents

Parent 1 Only

Parent 2 Only

Other: Guardian

* Street Address

* City

* Zip Code

Home Phone - Land Line

* Parent 1 Cell Phone

Parent 2 Cell Phone

* Which Phone Number is the best way to reach you?

Unless otherwise indicated here both parents will be given access to Religious School information and records.

Email is our primary form of communication.

* Parent 1 Email Address

* Re-Type Parent 1 Email Address

Parent 2 Email Address

Re-Type Parent 2 Email Address

Email - Other

Trip, Medical and Emergency Authorization

* First Aid

Yes - I authorize Fairmount Temple to give my child(ren) first aid.

No - I do not authorize Fairmount Temple to give my child(ren) first aid.

* Photo Release

Yes - I give my permission for my child(ren) to be photographed with the picture to be used for marketing purposes; including the Anshe Chesed Fairmount Temple Facebook Page and Anshe Chesed Fairmount Temple Blog.

No - I do not give my permission for my child(ren) to be photographed with the picture to be used for marketing purposes; including the Anshe Chesed Fairmount Temple Facebook Page and Anshe Chesed Fairmount Temple Blog.

* Contact Information

Yes - I give permission for our name, address, phone number and emails to be included and distributed in a roster to encourage Temple friendships.

No - I do not give permission for our name, address, phone number and emails to be included and distributed in a roster to encourage Temple friendships.

* Transportation

Yes - I give permission for my child(ren) to leave Fairmount Temple grounds to participate in Fairmount Temple programs. I understand that my child(ren) may be transported in a staff person's car or the car of another parent.

No - I do not give permission for my child(ren) to leave Fairmount Temple grounds to participate in Fairmount Temple programs. I understand that my child(ren) may be transported in a staff person's car or the car of another parent.

* Emergency Medical Treatment

Yes - In case of medical emergency, I authorize Fairmount Temple to arrange for an ambulance/emergency medical treatment for my child(ren). I understand I will contacted as soon as possible.

No - In case of medical emergency, I do not authorize Fairmount Temple to arrange for an ambulance/emergency medical treatment for my child(ren). I understand I will contacted as soon as possible.

* Contacting Physician and/or Dentist

Yes - In case of medical emergency, I authorize Fairmount Temple or emergency care provides to contact and obtain relevant information from my child(ren)'s dentist and/or physician.

No - In case of medical emergency, I do not authorize Fairmount Temple or emergency care provides to contact and obtain relevant information from my child(ren)'s dentist and/or physician.

* Authorization to participate in Religious School

I have read and agree with the above trip, medical and emergency authorization checked above. i agree to release Anshe Chesed Fairmount Temple, its lay leaders and staff from any claim or loss arising out of my child(ren)'s participation in Religious School. I have authority to sign this form on behalf of my family.

* Digital Signature

Please type your full legal name in agreement with the above Trip, Medical and Emergency Authorizations.

Emergency Contact Information (required fields, please use "NA" if not applicable)

* Emergency Contact - Name and Relationship to child(ren)

The emergency contact person should NOT be a parent

* Emergency Contact Cell Phone Number

* Physician's Name and Number

* Dentist Name and Number

Student 1

* Name

Nickname

* Prefered Pronouns

He / Him / His

She / Her / Hers

They / Them / Theirs

Fluid

Other

Hebrew Name

* Birthday, please include year

Student Cell Phone (if applicable)

Student email (if applicable)

Student summer camp attended Summer 2023

* For which program are you registering Student 1?

PreK Program on Sundays

Kindergarten Program on Sundays

First Grade Program on Sundays

Second Grade Program on Sundays

Third Grade Program on Sundays

Fourth Grade Program on Sundays

Fifth Grade Program on Sundays

Sixth Grade Program on Sundays

Seventh Grade Program on Mondays

Seventh Grade Alternative Program Sundays

Eighth Grade Program on Mondays

Eighth Grade Alternative Program Sundays

Ninth Grade Program on Mondays

Ninth Grade Alternative Program Sundays

Tenth Grade Program on Mondays

Tenth Grade Alternative Program Sundays

Eleventh Grade Program on Mondays

Eleventh Grade Alternative Program Sundays

Twelfth Grade Program on Mondays

Twelfth Grade Alternative Program Sundays

Students may request two friends to be with in class. We do our best to place them with at least one mutual request.

HEALTH AND OTHER INFORMATION; please check ALL that apply

ADD/ADHD

Allergies/Asthma

Emotional Disability

Fine Motor Difficulties

Gross Motor Difficulties

Frequent Headaches

Impaired Hearing

Impaired Vision

Learning Disability

Past Serious Illness or Injury

Regular Medication

IEP (please provide a copy for the office to keep on file)

If any of the above are checked please provide explanation

Tuition Payments: Only click the boxes if you are making an online payment at this time.

Kindergarten $250.00

Grades 1-12 $555.00

PreK Program $0.00

A payment plan with a non-refundable deposit of $100.00 per child or full payment is due with registration. If full payment is not received, please arrange a monthly or quarterly payment plan in the recurring payment window when prompted at check out. Contact Joey Laidman at [email protected] or 216.464.5890 for special circumstances.

Student 2

Name

Nickname

Prefered Pronouns

He / Him / His

She / Her / Hers

They / Them / Theirs

Fluid

Other

Hebrew Name

Birthday, please include year

Student Cell Phone (if applicable)

Student email (if applicable)

Student summer camp attended Summer 2021

For which program are you registering student 2?

PreK Program on Sundays

Kindergarten Program on Sundays

First Grade Program on Sundays

Second Grade Program on Sundays

Third Grade Program on Sundays

Fourth Grade Program on Sundays

Fifth Grade Program on Sundays

Sixth Grade Program on Sundays

Seventh Grade Program on Mondays

Seventh Grade Alternative Program on Sundays

Eighth Grade Program on Mondays

Eighth Grade Alternative Program on Sundays

Ninth Grade Program on Mondays

Ninth Grade Alternative Program on Sundays

Tenth Grade Program on Mondays

Tenth Grade Alternative Program on Sundays

Eleventh Grade Program on Mondays

Eleventh Grade Alternative Program on Sundays

Twelfth Grade Program on Mondays

Twelfth Grade Alternative Program on Sundays

Students may request two friends to be with in class. We do our best to place them with at least one mutual request.

HEALTH AND OTHER INFORMATION; please check ALL that apply

ADD/ADHD

Allergies/Asthma

Emotional Disability

Fine Motor Difficulties

Gross Motor Difficulties

Frequent Headaches

Impaired Hearing

Impaired Vision

Learning Disability

Past Serious Illness or Injury

Regular Medication

IEP (please provide a copy for the office to keep on file)

If any of the above are checked please provide explanation

Tuition Payments: Only click the boxes if you are making an online payment at this time.

Kindergarten $250.00

Grades 1-12 $555.00

PreK Progam $0.00

Student 3

Name

Nickname

Prefered Pronouns

He / Him / His

She / Her / Hers

They / Them / Theirs

Fluid

Other

Hebrew Name

Birthday, please include year

Student Cell Phone (if applicable)

Student email (if applicable)

Student summer camp attended Summer 2021

For which program are you registering student 3?

PreK Program on Sundays

Kindergarten Program on Sundays

First Grade Program on Sundays

Second Grade Program on Sundays

Third Grade Program on Sundays

Fourth Grade Program on Sundays

Fifth Grade Program on Sunday

Sixth Grade Program on Sundays

Seventh Grade Program on Mondays

Seventh Grade Alternative Program on Sundays

Eighth Grade Program on Mondays

Eighth Grade Alternative Program on Sundays

Ninth Grade Program on Mondays

Ninth Grade Alternative Program on Sundays

Tenth Grade Program on Mondays

Tenth Grade Alternative Program on Sundays

Eleventh Grade Program on Mondays

Eleventh Grade Alternative Program on Sundays

Twelfth Grade Program on Mondays

Twelfth Grade Alternative Program on Sundays

Students may request two friends to be with in class. We do our best to place them with at least one mutual request.

HEALTH AND OTHER INFORMATION; please check ALL that apply

ADD/ADHD

Allergies/Asthma

Emotional Disability

Fine Motor Difficulties

Gross Motor Difficulties

Frequent Headaches

Impaired Hearing

Impaired Vision

Learning Disability

Past Serious Illness or Injury

Regular Medication

IEP (please provide a copy for the office to keep on file)

If any of the above are checked please provide explanation

Tuition Payments: Only click the boxes if you are making an online payment at this time.

Kindergarten $250.00

Grades 1-12 $555.00

PreK Program $0.00

If you need to register a 4th Student please contact Elizabeth Kleckner at 216-464-5890

SETUP RECURRING PAYMENTS - Select option below

Select Yes to setup Recurring Payments

Recurring Payment

I want to make a recurring payment

Please enter the number of periods

Please bill me each period in the amount of

I agree to have my account information used to bill me as per the terms above. Additional payments will be made until the total number of periods are reached.

Recurring Total: