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2023 Annual Community Commitment and Affiliation Renewal
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B'Yachad School Registration 22/23
Please verify reCaptcha before submitting the form.
Congregation Shir Shalom B'Yachad School
Jewish Learning Together
B'Yachad
means "Together"
2022-23 Tuition and Fees
Note: Please
log into your congregant portal
before clicking on registration link.
If choosing monthly payments, or a down payment of $200
please choose
Bill to My account
on payment page.
Family Last Name
Student's Last Name
Tuition Schedule K to 7:
Grade Level
Rate
Kindergarten and 1st
$1045
2nd and 3rd
$1300
4th to 7th
$1510
**
Madrich Program (1st year mentor)
$540
Teens Together
$205
*
B'Yachad Preschool: 10 sessions
$225
*For registration link for preschool, see email or
CLICK HERE
** For
returning Madrich
, email Cathy to sign up:
Cathy@ourshirshalom.org.
Annual Registration Fee $100 per family, grades K-7.
Community Commitment must be in good standing in order for registration to be processed.
Religious School families need to be temple members by Sept 1.
An administrative fee discount of $25 per student Gr K-7 may be deducted from rates
if payment in full is made at time of registration.
Bar/Bat Mitzvah fees
: Two installments totaling $1250. The Bar/Bat Mitzvah fee is payable $625 in grade 5 with date assignment (
details on date selection and this payment will be emailed to you separately in January
) and $625 in grade 6 prior to assignment of Tutor. Both installments may be paid together. Account must be in good standing prior to assignment of event date and tutor.
Check here if you’d like the Monday 4:30-6:15 p.m. option if available for third through sixth graders only.
Check here if you’d like the Monday 4:30-6:15 p.m. option if available for third through sixth graders only.
Note: We will likely have a combination 3/4 and 5/6 class and need a minimum number for each to proceed.
LET'S GET STARTED! First, please select the number of children you are registering for school using this dropdown selection:
1
2
3
Upon completion, please double check that you filled in the box "no additional registrations" as needed and that the total fee reflects only the # of registrations you noted.
Name of Child1
Grade (e.g. K or 3)
Birthdate
Amount
Kindergarten / First: $1045
2nd and 3rd: $1300
4th to 7th: $1510
Madrich program (1st Year Mentor): $540.
Teens Together: $205
Name of Child2
Grade ( e.g. K or 3)
Birthdate
Amount
Kindergarten / First: $1045
2nd and 3rd: $1300
4th to 7th: $1510
Madrich Program (1st Year Mentor): $540
Teens Together: $205
No Additional registration
Name of Child3
Grade (e.g. K or 3)
Birthdate
Amount
Kindergarten / First: $1045
2nd and 3rd: $1300
4th to 7th: $1510
Madrich program (1st Year Mentor): $540
Teens Together: $205
No Additional Registration
Required $100 Family Registration Fee
for grades K-7.
Please
check the box below
next to $100 Registration Fee.
Not required for Teen and Madrich.
$100 Registration Fee (one per family, check box here):
$100 Registration Fee (one per family, check box here):
$25 Per Student Admin Fee Discount for paying school tuition
(Grades K to 7)
in full at this time: The option to choose this discount is available on the PAYMENT PAGE after submitting registration form.
Please fill in the
Discount Code on the payment page
after submitting registration with the correct discount if paying in FULL at this time.
If registering 1 child and paying in full, enter
25;
if registering 2 children and paying in full enter
50;
and if registering 3, enter
75.
(Discounts Codes to Enter on payment page: 25 or 50 or 75)
Check below to indicate if paying in full or in monthly installments:
Pay in full now.
Pay in nine monthly installments: September to May.
Pay a $200 down payment today, remaining balance will be charged September 1st.
If choosing either the monthly payment plan or the $200 deposit, please make sure you are logged into your congregant portal and choose
BILL TO MY ACCOUNT
on the payment page. We will charge you credit card on file a $200 downpayment if choosing this option or set up the monthly payment plan for Sept.
Total Tuition and Fees:
(Total of above tuition costs and registration). If paying in full, please enter the discount amount on payment page ($25 pay in full discount
per child
).
Last 4 digits of card to be used:
Please ensure that this credit/debit card is set up in "My Account" as one of your Payment Methods. We will use this card to pay the above. If you need to change the card on file, please do so now online or contact rabbiassist@ourshirshalom.org. If paying by check, please select Bill to My Account and mail check to our office.
Congregation Shir Shalom B'Yachad School
2022-23 Individual Student Registration Information
Please enter your information below and fill in all fields, along with a registration and health form f
or each child attending
B'Yachad school.
Please select the number of students
Please Select One
1
2
3
Student 1 Information
Student Last Name
Student First Name
Student's Hebrew Name
Student's Grade : Fall 2022
Prior Hebrew Instruction
yes
no
If not in Shir Shalom, # of years of Hebrew instruction?
Name of K- 12 School attending 9/2022
School District
Do you wish for school related emails to be sent to a parent or grandparent living in another household?
Yes
No
Name, relation to child & email address
IMPORTANT: Please indicate below about specific educational needs and/or conditions that apply to your child ln order for us to best serve him/her/them (confidential). If your child receives special services in public school and/or has an IEP, please describe how our school can help support the educational process for him/her/them.
Student 2 Information
Student Last Name
Student First Name
Student's Hebrew Name
Student's Grade : Fall 2022
Prior Hebrew Instruction
yes
no
If not in Shir Sholom, # of years of Hebrew instruction?
Name of K-12 School attending 9/2022
School District
Do you wish emails to be sent to a parent or grandparent living in another household?
yes
no
Name, relation & email address
IMPORTANT: Please indicate below about specific educational needs and/or conditions that apply to your child ln order for us to best serve him/her/them (confidential). If your child receives special services in public school and/or has an IEP, please describe how our school can help support the educational process for him/her/them.
Student 3 Information
Student Last Name
Student First Name
Student's Hebrew Name
Student's Grade :Fall 2022
Prior Hebrew Instruction
yes
no
If not in Shir Sholom, # of years of Hebrew instruction?
Name of K-12 School attending 9/2022
School District
Do you wish emails to be sent to a parent or grandparent living in another household?
yes
no
Name, relation to student & email address
IMPORTANT: Please indicate below about specific educational needs and/or conditions that apply to your child ln order for us to best serve him/her/them (confidential). If your child receives special services in public school and/or has an IEP, please describe how our school can help support the educational process for him/her/them.
Home Address
City
State
--Select State--
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip Code
Phone Number
Parent / Guardian Information
:
Parent1 Last Name
Parent1 First Name
Cell Phone
Parent #1 Email
Parent2 Last Name
Parent2 First Name
Cell Phone
Parent #2 Email
Please consider becoming a class parent.
(Please Check One)
Yes
Yes / If needed
No
2022/2023 Emergency/ Medical Information
Student 1 Information
Student Name
Responsible Parent & Telephone (during Religious school hours)
Name
Telephone
Alternate Contact For Emergency:
Phone
Relationship to student:
Child's Physician
Phone
Health Insurance Name:
Policy #
Allergies to food?
Symptoms:
Allergies to medications or any other allergies to note? If yes please also list symptoms.
Check here if allergies are seasonal.
Check here if allergies are seasonal.
Allergy prescriptions year round:
Yes
No
Does your child carry an epi-pen?
Is the child taking medication regularly (not for seasonal allergies) or being treated for any condition? If so, please list/explain:
Any other important medical/educational needs during Religious School hours:
Student 2 Information
Student Name
Grade
Check Here if Physician and Insurance info is the same as for 1st child.
Check Here if Physician and Insurance info is the same as for 1st child.
Child's Physician
Phone
Health Insurance Name
Policy #
Allergies to food
Symptoms
Allergies to Medications or any other allergies? If yes please also list symptoms.
Check here if allergies are seasonal
Check here if allergies are seasonal
Allergy Prescriptions year round
yes
no
Is the child taking medication regularly (not for seasonal allergies) or being treated for any condition? If so, please list/explain:
Any other important medical/educational needs during Religious School hours:
Student Name
Grade
Check Here if Physician and Insurance info is the same as for 1st child.
Check Here if Physician and Insurance info is the same as for 1st child.
Child's Physician
Phone
Health Insurance Name
Policy #
Allergies to food
Symptoms
Allergies to medications or any other allergies? If yes, please also list symptoms.
Check here if allergies are seasonal.
Check here if allergies are seasonal.
Allergy Prescriptions year round
yes
no
Does your child carry an epi-pen?
Is the child taking medication regularly (not for seasonal allergies) or being treated for any condition? If so, please list/explain:
Any other important medical/educational needs during B'Yachad hours:
The undersigned
does
hereby
g
ive permission for my child
("child's name")
to
attend and
participate in
any
Shir Shalom children/youth activities
,
events, retreats, childcare during the period
of
September
l,
2022 - Ma
y
31, 2023.
LIABILITY RELEASE:
In
consideration
of
Shir Shalom
allowin
g
the Participant to participate
in
B'Yachod activities (worship, meeting
s
,
activities,
and
field
trips)
.
I
,
th
e
u
n
dersigned
, do hereby
rele
as
e,
foreve
r
discharge
an
d
agree
t
o
hol
d
harml
es
s
Shi
r
Shalom
,
its
clergy,
directors,
em
p
loyees,
volunteers
an
d
teachers (collectively
herei
n the "
T
emple
"
)
fr
o
m
an
y and
al
l
liability
,
claim
s
o
r
d
emands
fo
r
accidental
pe
rsonal
in
j
u
ry
,
sickn
ess
o
r
d
eath,
a
s
w
e
l
l
a.s
pro
perty
damage
,,
..:
an
d
expe
ns
es
,
o
f
an
y
n
atu
re
wha
tsoever
whic
h
ma
y
be incurred by the
unde
rs
igne
d
and
the Participant while involved in the religious school activities.. I the
pa
rent or legal
gu
ardian of
this
Partici
p
ant hereby grant my
permission
for the Partici
p
ant to participate: fully in religious school activities, including trips awa
y
from the temple premise,. Furthermore, I, on behalf of
m
y
minor Participant,
hereby
assume all risk of accidental personal in
j
u
ry
,
sickness
death, dama
g
e and expense as a result of participation in
recreatio
n
and
work activities
in
vo
l
ve
d
therein
.
T
h
e undersigned
,
further
hereb
y
h
o
l
d harmless
a
n
d
in
d
emni
fy
sai
d
Templ
e
fo
r
any
liability sustained by said Tem
p
le as the result of the ne
g
li
g
ent, willful or intentional acts uf said Participant
,
Includin
g
expenses
Incurred
attendant thereto.
PHOTO RELEASE: The undersigned also
gives t
he Tem
p
le
p
ermission to use Participant's photograph
or
video image: on behalf
of
Shir Shalom including, but not limited to publicity, web conten
t,
advertising,
and marketin
g
.
MEDICAL TREATMENT PERMISSION:
I authorize
an
adult, in whose care the minor has been entrusted, to consent
to
any eme
rgency.
x
·
ray examination, anesthetic
,
medical, surgical
or
dental diagnosis or treatment and hospital care
, to
be rendered to the minor under the general
o
r special supervision
and
o
n
th
e
ad
v
ic
e
o
f any ph
ys
!clan
o
r
dentist
licensed
under
th
e provisions
o
f
th
e
Medica
l
P
ra
ctic
e Act
o
n
the
medical staff of a
licensed
hospital
or emergen
cy
care facilit
y
. The undersigned
shall
be
liable
and a
grees to
pay all cost and ex
penses
incurred in connection with
such
medical and dental services
rendered
to the aforementioned child or youth
p
ursuant
to
this authorization.
TRANSPORTATION
PERMISSION
:
T
h
e undersigned does also
hereb
y
give
p
e
r
m
is
sio
n for
m
y child/youth to
ri
d
e
i
n any
vehicl
e driven
by
a
n
approve
d
an
d
licensed
ADULT
cha
pe
rone while
attending
an
d participating
i
n
activities
sponsore
d
b
y
Shi
r
Shalom
. M
y
child/
y
outh
a
n
d
I
understand that a seat belt MUST
B
E
WO
R
N
A
T
AL
L
TI
M
E
S during
transportation.
*
Print Parent Name
Date
Thu, January 26 2023 4 Sh'vat 5783