Jewish Discovery Lab Registration 5782/2021-2022

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* Please enter the number of students

* Student 1 First Name

* Student 1 Last Name

Student's 1 Hebrew Name

Student's 1 Preferred Pronouns

Address

Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country

* Date of Birth

Student's 1 Email

Name of Public/Private School

* Grade (2021-2022 school year)

At the time of registration, is this student 1 in school

Please Select OneVirtualHybridIn-person

Does this child attend overnight camp during the summer ?

Please Select OneYesNo

Name of the Camp

Does this child has any food allergies ? If so, please list them.

Student 2 First Name

Student 2 Last Name

Student's 2 Hebrew Name

Student's 2 Preferred Pronouns

Same Address ?

YesNo

Address

Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country

Date of Birth

Student's 2 Email

Name of Public/Private School

Grade (2021-2022 school year)

At the time of registration, is this student 2 in school

Please Select OneVirtualHybridIn-person

Does this child attend overnight camp during the summer ?

Please Select OneYesNo

Name of the Camp

Does this child has any food allergies ? If so, please list them.

Student 3 First Name

Student 3 Last Name

Student's 3 Hebrew Name

Student's 3 Preferred Pronouns

Same Address ?

YesNo

Address

Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country

Date of Birth

Student's 3 Email

Name of Public/Private School

Grade (2021-2022 school year)

At the time of registration, is this student 3 in school

Please Select OneVirtualHybridIn-person

Does this child attend overnight camp during the summer ?

Please Select OneYesNo

Name of the Camp

Does this child has any food allergies ? If so, please list them.

Student 4 First Name

Student 4 Last Name

Student's 4 Hebrew Name

Student's 4 Preferred Pronouns

Same Address ?

YesNo

Address

Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country

Date of Birth

Student's 4 Email

Name of Public/Private School

Grade (2021-2022 school year)

At the time of registration, is this student 4 in school

Please Select OneVirtualHybridIn-person

Does this child attend overnight camp during the summer ?

Please Select OneYesNo

Name of the Camp

Does this child has any food allergies ? If so, please list them.

Student 5 First Name

Student 5 Last Name

Student's 5 Hebrew Name

Student's 5 Preferred Pronouns

Same Address ?

YesNo

Address

Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country

Date of Birth

Student's 5 Email

Name of Public/Private School

Grade (2021-2022 school year)

At the time of registration, is this student 5 in school

Please Select OneVirtualHybridIn-person

Does this child attend overnight camp during the summer ?

Please Select OneYesNo

Name of the Camp

Does this child has any food allergies ? If so, please list them.

Parent Information

* Parent / Guardian's 1 First Name

* Parent / Guardian's 1 Last Name

Home Phone

Work Phone

* Cell Phone

* Email

Parent/ Guardian's 2 First Name

Parent/ Guardian's 2 Last Name

Home Phone

Work Phone

Cell Phone

If parents are separated or divorced, please indicate where phone calls should be made and written correspondence sent:

Help us kvell! Please share your grandparents’ contact information with us. (List names and email addresses below)

In case of an emergency please contact:

* First Name

* Last Name

* Relationship

* Primary Phone Number

Secondary Phone Number

What kind of learner is your child? Does your child have any learning considerations in reading, writing, comprehension, organization, speech/language, attention, memory, etc. of which we should be aware? How does your child learn best?

What special services, if any, does your child receive in secular school or privately?

What are your child’s hobbies or special interests?

Is there anything else you would like to share about your child?

* Doctor's First Name

* Doctor's Last Name

Doctor's Phone Number

* Can your household support simultaneous virtual learning experiences?

Please Select OneYesNo

We're here for you. Do you need financial assistance?

Please Select OneYesNoDavid Rothenberg will follow up with families that select 'Yes'.

I hereby authorize Beth Am to take photographs and/or video recordings of my child and all members of my family for use in synagogue bulletins, publicity and the website.

Please Select OneYesNo

Total amount

REFUND POLICY

1. Deposit is non-refundable
2. If Child is withdrawn by:
- September 1, 2021: 80% tuition refunded
- October 1, 2021: 60% of tuition refunded
- Novermber 1, 2021: 40% of tuition refunded
- No refunds after November 1, 2021.

Sat, April 20 2024 12 Nisan 5784