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Name *
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E-mail Address *
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Has your street address changed since last year?
Yes
No
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Student 1 Name *
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Student 1 Class Selection *
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Student 1 Birthdate *
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Religious school grade (Should be the same grade as public school) *
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Student 1 Hebrew Name (ex: Johana bat Shlomo v'Sara)
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Student 1 Phone (cell)
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Student 2 Name
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Student 2 Class Selection
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Student 2 Birthdate
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Religious school grade (Should be the same grade as public school)
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Student 2 Hebrew Name (ex: Johana bat Shlomo v'Sara)
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Student 2 Phone (cell)
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Student 3 Name
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Student 3 Class Selection
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Student 3 Birthdate
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Religious school grade (Should be the same grade as public school)
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Student 3 Hebrew Name (ex: Johana bat Shlomo v'Sara)
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Student 3 Phone (cell)
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Student 4 Name
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Student 4 Class Selection
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Student 4 Birthdate
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Religious school grade (Should be the same grade as public school)
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Student 4 Hebrew Name (ex: Johana bat Shlomo v'Sara)
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Student 4 Phone (cell)
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Congregational Affiliation (UJS accepts unaffiliated students for a period of 1 year) *
Temple Emanuel
Ahavas Israel
Unaffiliated
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Student Street Address *
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City *
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State *
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Zip *
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Father Name *
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Father Phone
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Father Contact Email
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Mother Name *
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Mother Phone
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Mother Contact Email
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Does Student Live With Both Parents
Yes
No
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If student not living with parents, with whom does the student live?
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I, (parent name) *
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Grant permission for my son/daughter named above to be photographed during Beit Sefer B'yahad/United Jewish School activities. I understand that when photographs are used in print or on-line, no identifying information will be included. (check the box to grant permission)
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Grant permission for my son/daughter named above to leave Beit Sefer B'yahad/United Jewish School premises to participate in Religious School field trips. (check the box to grant permission)
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Grant permission for my son/daughter named above to be taken to the nearest emergency room, in case of emergency. I understand that every effort will be made to reach either or both parents by phone as soon as possible.
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Name and Relationship of Emergency Contact
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Home/Cell Phone of emergency contact
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Physician Name and Phone
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List allergies/special needs and medications (specify student)
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Does your child receive any special education services at school? Please describe. Please specify child.
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Does your child have an IEP (Individual Education Plan) at his/her school? Please describe how best to implement the plan in our program. Please specify child.
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Would you allow the school to provide us with a copy of the IEP?
Yes
No
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Contact person and phone number for school.
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Please describe any accommodations your child requires to be successful at school. Please specify child.
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By checking this box and typing my name in the "Electronic Signature" field below I certify that I am the authorized parent/ guardian of the child specified and that I am voluntarily submitting this registration form for review by the Staff of United Jewish School *
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Electronic Signature *
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