The Zelda & Herman Schwartz Hebrew School
of Temple Sholom

Registration 2017 - 2018
Student Information
Student 1
Check if Post Bar/t Mitzvah
Gender:
Name:
Female
Male
Hebrew Name:
Date of Birth:
Public School Grade as of Sept. 2017:
Name or number School child attends:
Student 2
Check if Post Bar/t Mitzvah
Gender:
Name:
Female
Male
Hebrew Name:
Date of Birth:
Public School Grade as of Sept. 2017:
Name or number School child attends:
Student 3
Gender:
Name:
Female
Male
Hebrew Name:
Date of Birth:
Public School Grade as of Sept. 2017:
Name or number School child attends:
Parent/Guardian Information
Home Address:
Home Phone Number:
Parent 2/Guardian Name:
Parent 1/Guardian Name:
Work Phone Number:
Work Phone Number:
Parent 2 Cell Phone number:
Parent 1 Cell Phone number:
Parent 2 e-mail address:
Parent 1 e-mail address:
Emergency Contact Information
2. Name
1. Name
Phone Number
Phone Number
Authorized Pickup Information
2. Name
1. Name
Medical Information
Please inform us of any allergies, medical conditions, learning needs, or anything you feel we
should be aware of so that we may serve your child to the best of our abilities:
Dentist's Name:
Doctor's Name:
Phone Number
Phone Number
Medical Insurance Company
Policy Number
Group Number
authorize the staff of Temple Sholom to obtain
In case of emergency, I
emergency medical treatment for my child.  I understand that all efforts will be made to contact me or
my emergency contacts immediately.
Field Trip Consent
I give permission for my child/children listed above to participate fully inn all activities and/or field trips with the
Zelda & Herman Schwartz Hebrew School of Temple Sholom during the 2017-2018 school year.
Parent/Guardian Name
Photo/Video Authorization
I give permission for my child/children listed above to appear in photographs, videos, or the Temple
Website to be used by Temple Sholom and the Hebrew School for publicity, marketing, and/or advertising
purposes. No personal information shall be given out identifying a student's name, age, or grade.
Parent/Guardian Name
BUS TRANSPORTATION
For the 2017-2018 School year, Bus Transporation is available from PS 236, PS 312, and PS 222. The fee for
bus service is $200 for the first child, and $100 for each additional child with a maximum amount of $400 for
three or more children.  Please Call June Koutros at 718-812-3784  or email her at jek0630@aol.com to find
out if your child could receive bus transportation from a school other than those mentioned.
Check here if bus pick up is needed
Notices are sent out by email.  Please make sure you have an up to date email
address listed on the registration form.  If you would like paper notices sent home
instead please check this box.
TEMPLE MEMBERSHIP

Temple Membership includes free Hebrew School Tuition and High Holiday Tickets for the immediately family.

Additonal yearly fees include a $50 material and book fee for each child, a $50 secuirty fee per family, and a
$50 workshop fee for each child.