JACTS Registration Forms

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.