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Religious School Registration Form

L'Dor V'dor / From Generation to Generation

Congregation Etz Chaim Religious School

Shalom everyone!

I am excited to lead the Congregation Etz Chaim community as Religious School Director for the 2016-2017 school year. I look forward to another fantastic school year educating our children about Judaism, Israel, and Hebrew!

Religious school will continue to be located at First Christian Church (807 SE 14th St, Bentonville), from 10 AM-12 noon. Families, please join us for Hatikvah, a fun song, and announcements right at 10 AM. As we did last year, we will form a carpool line at noon in the back of the church for pick-up, and your child's teacher will deliver your child to you.

Torah Tots will continue this year for three and four year olds. Classes will be held monthly, beginning at 10:15 (after announcements). Younger siblings are welcome to attend.

In addition to Sunday Religious School, beginning in 5th grade, we will continue with our Wednesday Hebrew program that is devoted entirely to Hebrew studies. Students will continue in the Wednesday Hebrew program right up until the time of Bar/Bat Mitzvah. It will meet on Wednesdays from 6-7:15 PM at Bob Myerson’s home at 101 Somerset, Bentonville.

Similar to past years, we will have a parent (“Mensch of the Week”) each week to assist with snack. Parents will not be required to stay for the whole class but will need to set up the snack table when they arrive at the beginning of school. I will send out the parent schedule before school begins.

Please print, fill-out the registrations forms by August 15, 2016, so that we may adequately plan for attendance.

Thank you, Helene Carter, Religious School Director

(helenecarter26@gmail.com, 479-883-8598)

* Student 1 First Name

* Student 1 Last Name

Student 1 Nickname

Student 1 Hebrew Name

Student 1 Date of Birth

Student 1 Age as of 9/1/16

Student 1 Grade Level

Student 1 Allergies to Medications

If your student does not have any allergies to medications, please enter "None" in the box above.

Student 1 Allergies to Food

If your student does not have any allergies to food or special dietary needs please enter "None" in the box above.

Please note any/all conditions for which your child is currently receiving treatment, and any other significant medical information:

Student 2 First Name

Student 2 Last Name

Student 2 Nickname

Student 2 Hebrew Name

Student 2 Date of Birth

Student 2 Age as of 9/1/16

Student 2 Grade Level

Student 2 Allergies to Medications

If your student does not have any allergies to medications, please enter "None" in the box above.

Student 2 Allergies to Food

If your student does not have any allergies to food or special dietary needs please enter "None" in the box above.

Please note any/all conditions for which your child is currently receiving treatment, and any other significant medical information:

Student 3 First Name

Student 3 Last Name

Student 3 Nickname

Student 3 Hebrew Name

Student 3 Date of Birth

Student 3 Age as of 9/1/16

Student 3 Grade Level

Student 3 Allergies to Medications

If your student does not have any allergies to medications, please enter "None" in the box above.

Student 3 Allergies to Food

If your student does not have any allergies to food or special dietary needs please enter "None" in the box above.

Please note any/all conditions for which your child is currently receiving treatment, and any other significant medical information:

* Parent(s) 1 - First Name(s)

* Parent(s) 1 - Last Name(s)

* Parent(s) 1 - Home Phone Number

* Parent(s) 1 - Cell Phone Number

* Parent(s) 1 - Email Address

* Parent(s) 1 Street Address

* Parent(s) 1 City

* Parent(s) 1 Zipcode

Parent(s) 2 - First Name(s)

* Parent(s) 2 - Last Name(s)

Parent(s) 2 - Home Phone Number

Parent(s) 2 Cell Phone

Parent(s) 2 - Email Address

Parent(s) 2 Street Address

Parent(s) 2 City

Parent(s) 2 Zipcode

* Emergency Contact Name 1

* Emergency Contact 1 Relationship to Child(ren)

* Emergency Contact 1 Phone Number

* Emergency Contact Name 2

* Emergency Contact 2 Relationship to Child(ren)

* Emergency Contact 2 Phone

* Physician Name

* Physician Phone Number

* Health Insurance Carrier

* Health Insurance Identification #

* Health Insurance Group/Policy #

* Health Insurance Claims/Authorization Phone #

* Medical Acknowledgement

Medical Acknowledgement

By checking the above box, I understand and agree that in case of an emergency or injury to the above enrolled child, such action will be taken and medical treatment administered as deemed necessary by the school or its employees. I hereby release the school, its employees and agents from any claim or liability with respect to the same. I give the school such authorization that permits any person or hospital to provide such treatment to my child as may be advisable in the circumstances, and this shall be sufficient authority for doing so.

* Photographic Release

Please Select OneYesNo

I give permission for my child’s photo to be posted on the Congregation Etz Chaim website, to be included in weekly parent updates, and/or to be printed in the community bulletin or other public materials.

* Substitute Teacher

Please Select OneYesNo

Please indicate if you would be willing to be listed as an “on-call” substitute teacher. We will try our best to contact you in advance but we are looking for some volunteers that can step in for any last minute needs.

Tue, May 17 2022 16 Iyar 5782