Student Name _______________________________ Confidential Registration Page 1 of 3
School Director,Rabbi Sara Shendelman
510-644-2956
moretorah@aol.com
http://jewishacts.blogspot.com/
Registration 2010-2011
PLEASE PRINT
Student Information Please fill out a separate form for each child
Student’s Name _____________________________________________________________________
Last First Hebrew?
Age ________ Date of Birth ____/____/____ Grade entering ______ School____________________
Student’s Address _______________________________City__________________ Zip____________
Home Telephone __________________________ Other Telephone __________________________
Child lives with Mother Father Other Please specify:
Parent/Guardian Information Please provide information for each adult child lives with, continue on back if necessary.
Name _____________________________ Name _______________________________
Last First Hebrew Last First Hebrew
Home address if different from student Home address if different from student
________________________________ ___________________________________
Home Phone _______________________ Home Phone _______________________
Cell Phone_________________________ Cell Phone____________________________
E-mail____________________________ E-mail_______________________________
School information should be sent to: Mother Father both Other Guardian
Emergency Information
Please provide the name of a friend or relative who can be reached on Sunday if parent is Not available.
(Please be sure they have consented to act on your behalf)
Name_______________________________ Phone ________________________
Relationship to Child__________________________________________________
Name_______________________________ Phone ________________________
Relationship to Child__________________________________________________
Student Name _______________________________ Confidential Registration Page 2 of 3
Publicity Release for Minors
We occasionally submit pictures of our activities for publication and/or post them on our website. Please tell us if we have your permission to publish pictures of your child(ren). As a matter of policy we DO NOT identify children by name.
_____ I hereby consent to the publication of photographs, video or quotes by my son/daughter in print or
on the JACTS website for the school year 2010-2011.
_____ No, I do not give my permission.
Parent’s Signature: Date
Field Trip Permission Slip
We occasionally walk away from school grounds to nearby parks, recreation centers, etc. during class as part of the curriculum.
I give permission for my child _______________________ to accompany his/her class on field trips during the school year 2010/2011.
Parent’s Signature: Date ____________________________
Additional Information
Does your child have any medical/ condition requiring special care?
If yes, please describe and indicate precautions needed and/or medications taken: _____________________________________
Does your child have any allergies, including FOOD ALLERGIES
If yes, please specify dangerous FOODS and indicate precautions needed:
Are there any learning or behavioral difficulties that we should be aware of? (Confidential) continue on back:
_____________________________________________________________________________
Please specify your goals for your child’s learning and participation at JACTs
Student Name _______________________________ Confidential Registration Page 3 of 3
Chochmat HaLev membership?____________ Synagogue/Other Affiliation ________________
Any conversions or adoptions in your family? _________________
Has your child had any previous Jewish education? ____ if yes, indicate name of school and years attended
Enrollment Policy:
There is a $50 registration fee which can be waived if payment is made all at once.
Tuition: Checks should be made payable to JACTS
Sunday Class Aleph $500
Sunday Class Bet $750
B’Nei Mitzvah $1200
Weekday Aleph/Bet TBD
If paying full tuition will present a financial hardship, note the adjusted amount your family can pay for tuition. All adjustment requests are subject to both need and availability of funds.
