HCS Hebrew School Registration Form - Hebrew Congregation of Somers

Phone number *

Name of second parent or caregiver, if applicable

Phone number

Emergency Contact/Permission to pick up Name *

Emergency Contact Phone number *

Emergency Contact Relationship *

Do you have any special interests that you would like to share with our Hebrew School and synagogue community at large?

Household members

***REQUIRED*** Please enter this information for each child you are enrolling

Please select a program for FIRST child listed: *

K-4 Sundays 10:00 to 12:00 Tuition $1025 plus $95 materials

5-7 Sundays 10:00 to 12:00 and Tuesdays 4:15 to 6:00 Tuition $1200 plus $95 materials

Does your first child have allergies?

Current Medications

If your child has any physical, medical, learning, social or behavioral issues that we should be aware of, please enter them here.

. We welcome your child with open arms, and strive to create as supportive an environment as possible. We appreciate this information and will keep it confidential. If your child has an IEP or 504 Plan at school, we would greatly appreciate if you could attach it here or send to Ann: hcseddirector@gmail.com.

Please select a program for SECOND child listed:

K-4 Sundays 10:00 to 12:00 Tuition $1025 plus $95 materials

5-7 Sundays 10:00 to 12:00 and Tuesdays 4:15 to 6:00 Tuition $1200 plus $95 materials

Does your second child have allergies?

If your child has any physical, medical, learning, social or behavioral issues that we should be aware of, please enter them here.

. We welcome your child with open arms, and strive to create as supportive an environment as possible. We appreciate this information and will keep it confidential. If your child has an IEP or 504 Plan at school, we would greatly appreciate if you could attach it here or send to Ann: hcseddirector@gmail.com.

Please select a program for THIRD child listed:

K-4 Sundays 10:00 to 12:00 Tuition $1025 plus $95 materials

5-7 Sundays 10:00 to 12:00 and Tuesdays 4:15 to 6:00 Tuition $1200 plus $95 materials

Does your third child have allergies

If your child has any physical, medical, learning, social or behavioral issues that we should be aware of, please enter them here.

. We welcome your child with open arms, and strive to create as supportive an environment as possible. We appreciate this information and will keep it confidential. If your child has an IEP or 504 Plan at school, we would greatly appreciate if you could attach it here or send to Ann: hcseddirector@gmail.com.

Would you like us to contact you to arrange a confidential meeting to discuss any areas of concern prior to the start of the Hebrew school year?

If yes, please provide best contact # or email:

In an emergency, HCS has my permission to contact “911” to request aid. HCS and the rescue squad have my permission to take my child to the emergency room of the nearest hospital. The rescue squad and hospital have my authorization to provide treatment.

Do you have any special interests that you would like to share with our Hebrew School and synagogue community at large?

Hebrew Congregation of Somers may photograph my child for anonymous (unlabeled) use:

Within the synagogue

On our website

On Social Media

Print Media

I hereby give permission to have my child listed in the Hebrew School Directory.

Families with children ages 0-8 are automatically enrolled in PJ Library; look out for your first storybook in the next few weeks. Families with children ages 9-12 are invited to sign up for PJ Our Way, PJ Library's chapter book program at pjourway.org. *

PJ Library sends high-quality Jewish children's books to families around the world every month, completely free. The stories, along with PJ Library's vast online resources and community events, spark conversations that inspire the whole family to celebrate what they love about Jewish life.

I confirm that my family includes Jewish member(s) and is eligible for PJ Library. By sharing the following information I acknowledge it will be shared with PJ Library in order to begin receiving free monthly books. *

PJ Library is intended for families raising children with Judaism as a part of their lives.

Signature

In an emergency, the staff of Hebrew Congregation of Somers(HCS) has my permission to contact “911” and request the assistance of a rescue squad. HCS and the rescue squad have my permission to take my child to the emergency room of the nearest hospital. The rescue squad, hospital and its staff have my authorization to provide treatment necessary for the well-being of my child.

Signature of parent or guardian. *