Jewish Discovery Lab Registration Grades K-7 5783/2022-2023

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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 School

* Incoming Grade (2022-2023 school year)

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.

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 are your child’s hobbies or special interests?

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

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

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 School

Incoming Grade (2022-2023 school year)

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.

What are your child’s hobbies or special interests?

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

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

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 School

Incoming Grade (2022-2023 school year)

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.

What are your child’s hobbies or special interests?

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

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

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 School

Incoming Grade (2022-2023 school year)

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.

What are your child’s hobbies or special interests?

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

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

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 School

Incoming Grade (2022-2023 school year)

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.

What are your child’s hobbies or special interests?

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

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

Parent Information

* Parent / Guardian's 1 First Name

* Parent / Guardian's 1 Last Name

* Mobile Phone

Alternate Phone

* Email

* Preferred Contact Methods

Phone CallText MessageEmail

Parent/ Guardian's 2 First Name

Parent/ Guardian's 2 Last Name

* Mobile Phone

Alternate Phone

Preferred Contact Method - Guardian 2

Phone CallText MessageEmail

If parents are separated or divorced, or if one guardian is the preferred point of contact, 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

Interested in transportation?

For 2nd-6th grade students, would you be interested in van transportation on Wednesday afternoons from your child’s school to Beth Am? (Additional cost of approximately $18-25 a ride based on how many students sign up)

What time does your child(ren)'s school let out?

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

Please Select OneYesNoAlex Pomerantz 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

If Child is withdrawn by:
- September 1, 2022: 80% tuition refunded
- October 1, 2022: 60% of tuition refunded
- November 1, 2022: 40% of tuition refunded
- No refunds after November 1, 2022.

Thu, December 19 2024 18 Kislev 5785

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