University Synagogue Campus. Living Judaism Program Student Registration Information

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1 Download this form to your device and you can type your answers into the fields. Save and then to University Synagogue Living Judaism Program Student Registration Information IMPORTANT: Please complete the following information for EACH child: University Synagogue Campus Living Judaism at Home (Please Print) Student s Name: Last First Middle Hebrew Name Male Female Birth Date: / / Enter grade or select class at US: New student to University Synagogue: Yes No Name of Secular School and City: Parent/Guardian Jewish (Work Phone) (Cell Phone) Street City Zip Code Parent/Guardian Jewish (Work Phone) (Cell Phone) Street City Zip Code 1

2 Student s Physician: Student s Dentist: STUDENT MEDICAL Does your child have any allergies or conditions that may require immediate or emergency care? Yes No If yes, please list and describe treatment in the space provided below: Does your child have any medical conditions or take any medication(s)? Yes No If yes, please list and describe in the space provided below: 2

3 EMERGENCY CONTACTS Name: Relationship: Cell/Work Phone: Name: Relationship: Cell/Work Phone: MEDICAL INSURANCE Insurance Company ID Number Policy Number Name of Policy Holder MEDICAL RELEASE AUTHORIZATION In case of an accident or serious illness, I request that University Synagogue contact me immediately. If the school is unable to reach me, I hereby authorize the Living Judaism Program, or its authorized agent, to secure proper treatment for my child. Yes No (Signature of Parent/Guardian) (Date) 3

4 HELP US MEET YOUR CHILD S NEEDS In an effort to provide the best educational experience for your child, please provide any information pertaining to social, physical or emotional issues that may be a factor in the classroom. Please include strengths, talents and interests as well as challenges. ROOM PARENTS Parents who would like to participate in their child s Jewish education by helping to plan holiday, family Shabbat programs and special activities in the Living Judaism Program. Parent Name(s): Yes, I would like to participate as a room parent. Grade WEEKLY LIVING JUDAISM UPDATE FLYERS In an effort to preserve our environment, the University Synagogue Living Judaism Program is doing its part by joining global efforts and going green. Most school information will be sent via on a weekly basis. Please provide current address(s) and also text number(s) where you can receive emergency information. Emergency Text Message Cellphone# Emergency Text Message Cellphone# 4

5 PARENTAL CONSENT / DECLINE FOR STUDENT PHOTO RELEASE During the school year special events and class activities at the US Living Judaism Program are illustrated in the local newspapers and magazines. We also use student photos in our school curriculum when communicating to other students across the globe in our grade level pen pals program. The US Living Judaism Program requires parental permission in order to use photos that include your child with any school or classroom publicity. CONSENT I, give University Synagogue Living Judaism (Parent s Name) permission to use photos of class or activity/special events that include my child for publication or curriculum purposes during the school year. (Parent s Signature) (Date) DECLINE I, decline University Synagogue Living Judaism (Parent s Name) to use photos of class or activity/special events that include my child for publication or curriculum purposes during the school year. (Parent s Signature) (Date) 5

6 Previous Religious Educational Settings You have my permission to contact any previous Religious School settings where our child has been enrolled. Any such information provided to us is kept strictly confidential and is used solely for the purpose of determining the best placement and setting for the child. Yes No (Check appropriate) (Parent Signature) Name of Previous Facility: Contact Person: Dates attended: Professional Service Providers You have my permission to contact current or previous professional service providers for our child (for example, speech therapist, physician, physical therapist). Any such information provided to us is kept strictly confidential and is used solely for the purpose of determining how best to serve the child s needs while the child is enrolled and attends the Living Judaism Program. Parent(s) will be notified prior to contact. Yes No (Check appropriate) (Parent Signature) Name of Previous Facility: Contact Person: Dates attended: Parent Name Date 6

7 University Synagogue Living Judaism Program Waiver, Release and Medical Authorization I hereby give permission for my child to participate in events located at University Synagogue Irvine or off site activities through the Synagogue, CA during the school year. I, the undersigned parent/guardian/legal representative hereby release and discharge University Synagogue, its officers, employees, agents and servants (herein collectively University Synagogue ) from any and all liability arising out of or in connection with the above event. Liability means all claims, demands, losses, causes of action, suits, damages, or judgments of any and every kind that I and my child, our heirs, executors, administrators or assignees may have against University Synagogue because of any death, personal injury or illness, or because of any loss or damage, including loss to property that occurs during the above nature walk activity and that results from any cause other than the direct negligence of University Synagogue. This release applies to any liability my child or I may have a right to claim personally or by and through any other person. In the event of any emergency, I hereby consent to whatever anesthetic, medical, dental or surgical diagnosis or treatment, radiologic study and hospital care from a licensed physician and/or surgeon as deemed necessary for the safety and welfare of my child, consistent with any prior authorizations and medical releases I previously have provided to University Synagogue. I understand that the resulting expenses will be the responsibility of the parent(s) or participant. Name of Parent/Guardian Signature of Parent/Guardian Telephone Number Cellphone Number(s) Health Insurance Company Policy Number Date If your child has special health or pharmaceutical needs or allergies to medication or if there is someone other than the parent who should be contacted in an emergency, please list: 7

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