2023-2024 Polsky Religious School Registration - Form

* Is your family new to our school?

Please Select OneNoYes

IMPORTANT: If you want to apply for a scholarship, do NOT complete this electronic registration form. You will need to turn in the paper registration form to the PRS Office by May 1st, 2023. Additionally, you will need to turn in the scholarship form (and all supporting tax documents) to Richard Simon by August 7th, 2023.

Section A: Family Contact Information

* First Name (Primary)

* Last Name (Primary)

* Email (Primary)

* Phone (Primary)

* Relationship to Student(s) (Primary)

* Street Address (Primary)

Street Address Line 2 (Primary)

* City (Primary)

* State (Primary)

* ZIP (Primary)

* Is there a secondary contact?

Please Select OneNoYes, at the same address as the primary contactYes, but at a different address than the primary contactIf there is a secondary contact, all emails and mailings will go to both contacts. In case of urgent need, the primary contact will be notified first.

* First Name (Secondary)

* Last Name (Secondary)

* Email (Secondary)

* Phone (Secondary)

* Relationship to Student(s) (Secondary)

* Street Address (Secondary)

Street Address Line 2 (Secondary)

* City (Secondary)

* State (Secondary)

* ZIP (Secondary)

* Emergency Contact Name

* Emergency Contact Phone

* Emergency Contact Relationship

Section B: Student Enrollment Information

Student 1 Information

* Student 1 First Name

* Student 1 Last Name

* Student 1 Birthdate

* Student 1 Hebrew Name

Student 1 Nickname (if applicable)

* Student 1 Grade in Religious School

This is the same as your child's grade for the 2023-2024 secular school year unless you have made other arrangements with the religious school office.

* Student 1 Secular School Name

Student 1 Email (if applicable)

Information will not be shared publicly. Parents will be copied on all communication to students.

Student 1 Phone (if applicable)

Information will not be shared publicly. Students will not be contacted independently from parents.

At Congregation Beth Shalom we strive to establish an environment in which all types of learners may thrive. Information you provide about your child’s learning strengths and challenges will assist in our efforts to accommodate and provide for those needs. Any information you provide will be held in the strictest confidence and will be shared only as necessary to provide your child with a quality educational experience.

* Student 1 Special Learning Needs

Please Select OneNoYes (IEP or 504)Yes (no clinical label or formal plan in place yet)If yes, Civia White would love to meet with you and your child’s teacher before the school year begins so that we are able to discuss the best ways to support your child from the outset. If you are comfortable we invite you to send any documentation ahead of time to cwhite@bethshalomkc.org.

* Student 1 Medical

Please Select OneNoYesDoes your child take any medications, have any illness or chronic condition that school personnel needs to be aware of (i.e., asthma, dietary restrictions, allergies, ADD/ADHD, hearing, vision, speech)?

Student 1 Medical Details

If you answered yes on the question prior, please describe.

Please note: Congregation Beth Shalom cannot be responsible for administering any daily medications to any student. Please administer your child's medication at home, before your child comes to school. If you child has severe allergies, please supply any needed rescue medications. Parents will receive a phone call if their child requests any over the counter pain medications.

What else would you like Civia White and your child's teacher to know about your child?

Feel free to share any special interests, talents, struggles, aversions, or pieces of relevant personal history that you feel might be relevant and that you ae comfortable sharing.

Student 2 Information

* Student 2 First Name

* Student 2 Last Name

* Student 2 Birthdate

* Student 2 Hebrew Name

Student 2 Nickname (if applicable)

* Student 2 Grade in Religious School

This is the same as your child's grade for the 2023-2024 secular school year unless you have made other arrangements with the religious school office.

* Student 2 Secular School Name

Student 2 Email (if applicable)

Information will not be shared publicly. Parents will be copied on all communication to students.

Student 2 Phone (if applicable)

Information will not be shared publicly. Students will not be contacted independently from parents.

* Student 2 Special Learning Needs

Please Select OneNoYes (IEP or 504)Yes (no clinical label or formal plan in place yet)If yes, Civia White would love to sit down with you and your child’s teacher before the school year begins so that we are able to discuss the best ways to support your child from the outset. If you are comfortable we invite you to send any documentation ahead of time to cwhite@bethshalomkc.org.

* Student 2 Medical

Please Select OneNoYes

Does your child take any medications, have any illness or chronic condition that school personnel needs to be aware of (i.e., asthma, dietary restrictions, allergies, ADD/ADHD, hearing, vision, speech)?

Student 2 Medical Details

If you answered yes on the prior question, please describe.

What else would you like Civia White and your child's teacher to know about your child?

Student 3 Information

* Student 3 First Name

* Student 3 Last Name

* Student 3 Birthdate

* Student 3 Hebrew Name

Student 3 Nickname (if applicable)

* Student 3 Grade in Religious School

This is the same as your child's grade for the 2023-2024 secular school year unless you have made other arrangements with the religious school office.

* Student 3 Secular School Name

Student 3 Email (if applicable)

Information will not be shared publicly. Parents will be copied on all communication to students.

Student 3 Phone (if applicable)

Information will not be shared publicly. Students will not be contacted independently from parents.

* Student 3 Special Learning Needs

* Student 3 Medical

Please Select OneNoYes

Student 3 Medical Details

If you answered yes on the prior question, please describe.

What else would you like Civia White and your child's teacher to know about your child?

Student 4 Information

* Student 4 First Name

* Student 4 Last Name

* Student 4 Birthdate

* Student 4 Hebrew Name

Student 4 Nickname (if applicable)

* Student 4 Grade in Religious School

This is the same as your child's grade for the 2023-2024 secular school year unless you have made other arrangements with the religious school office.

* Student 4 Secular School Name

Student 4 Email (if applicable)

Information will not be shared publicly. Parents will be copied on all communication to students.

Student 4 Phone (if applicable)

Information will not be shared publicly. Students will not be contacted independently from parents.

* Student 4 Special Learning Needs

* Student 4 Medical

Student 4 Medical Details

If you answered yes on the prior question, please describe.

What else would you like Civia White and your child's teacher to know about your child?

Section C: Release Forms

By signing my name below, my child(ren) have permission to participate in the Polsky Religious School of Congregation Beth Shalom. I hereby authorize the Education Director, or person designated by the Education Director, to obtain emergency medical care for my child(ren) in the event such care is indicated. I give my permission for my child(ren) to receive emergency medical care by any nurse, doctor, paramedic or member of a medical staff of a hospital licensed by the state of Kansas. I understand that every effort will be made to notify a parent/guardian prior to treatment.

I certify that my child(ren) is(are) in good physical health. They have my permission to participate in all activities that are part of the regular religious school program.

* Medical Release: Enter your name below

By typing my name, I confirm I have read, understand and agree to the above.

* Doctor's Name

* Doctor's Phone Number

* Health Insurer

* Policy Number

* Group Number

Media Release

From time to time your child(ren)’s photo may be taken in our classrooms or special events. We use these photos on the synagogue website, on our synagogue display boards, in the weekly Connect email, the monthly Scroll newsletter, as well as our Facebook page and other publicity materials.

* I give my permission for my child(ren)'s photo to be used:

Please Select OneOn any materialsI do NOT give my permission for my child’s image to be used

This year we plan on creating a 2023-2024 Polsky Religious School Directory, which will be distributed to the parents. This information will include the students name, parents names, emails, and a primary phone number.

* Regarding the 2023-2024 Polsky Religious School Directory

Please Select OneI DO give my permission to include our information in the directory.I do NOT give my permission to include our information in the directory.

Section D: Congregation Community

Please let us know below, if you would like to be involved as a parent volunteer and community member.

Ongoing Opportunities

Room Parent

If other, what would you like to share?

Section E: Payment Information

Total Amount