Академический Документы
Профессиональный Документы
Культура Документы
Parent 1 Information
Name: ___________________________
Address: _________________________
City: _________ State: ____ Zip: ______
Home Phone: _____________________
Cell Phone: _________________ ______
Work Phone: ______________________
Occupation: _______________________
Email: _____________________ ______
Union Temple Member: Yes
Parent 2 Information
Name: ___________________________
Address: _________________________
City: _________ State: ____ Zip: ______
Home Phone: _____________________
Cell Phone: _______________________
Work Phone: ______________________
Occupation: _______________________
Email: ____________________________
No
Student Information
Student 1:
Name: _____________________________
Hebrew Name: ______________________
Gender: ____________________________
Birthdate: ___________________________
2015-2016 Grade: ____________________
Student 3:
Name: ______________________________
Hebrew: Name: _______________________
Gender: _____________________________
Birthdate: ____________________________
2015-2016 Grade: _____________________
Student 2:
Name: ______________________________
Hebrew Name: _______________________
Gender: _____________________________
Birthdate: ____________________________
2015-2016 Grade: _____________________
Parent 2 Information
Name: __________________________
Address: ________________________
City: _________ State: ____ Zip: _____
Home Phone: ____________________
Cell Phone: ______________________
Work Phone: _____________________
Student 1: _________________________________
Has your child ever been evaluated for social/ emotional concerns? ___________________
Does your child have an IEP? _________________
Vision Challenges- Wears Glasses_____ Wears Contacts___ Color Blind___ Visual Processing Disorder____
Reading challenges- Dyslexia_____ Reads below Grade Level______ Difficulty understanding or processing
written information______
Auditory challenges- Deafness____ Auditory Processing Disorder____ Difficulty understanding or processing
oral information______
Attention challenges- ADD/ADHD______ Easily distracted_____ Tendency to be overactive_____
Emotional challenges- Especially sensitive___ Difficulty interacting with peers____ Difficulty interacting with
adults_____
Student 2: _________________________________
Has your child ever been evaluated for social/ emotional concerns? ___________________
Does your child have an IEP? _________________
Vision Challenges- Wears Glasses_____ Wears Contacts___ Color Blind___ Visual Processing Disorder____
Reading challenges- Dyslexia_____ Reads below Grade Level______ Difficulty understanding or processing
written information______
Auditory challenges- Deafness____ Auditory Processing Disorder____ Difficulty understanding or processing
oral information______
Attention challenges- ADD/ADHD______ Easily distracted_____ Tendency to be overactive_____
Emotional challenges- Especially sensitive___ Difficulty interacting with peers____ Difficulty interacting with
adults_____
Student 3: _________________________________
Has your child ever been evaluated for social/ emotional concerns? ___________________
Does your child have an IEP? _________________
Vision Challenges- Wears Glasses_____ Wears Contacts___ Color Blind___ Visual Processing Disorder____
Reading challenges- Dyslexia_____ Reads Below Grade Level______ Difficulty understanding or processing
written information______
Auditory challenges- Deafness____ Auditory Processing Disorder____ Difficulty understanding or processing
oral Information______
Attention challenges- ADD/ADHD______ Easily distracted_____ Tendency to be overactive_____
Emotional challenges- Especially sensitive___ Difficulty interacting with peers____ Difficulty interacting with
adults_____
Please elaborate on any of the above. If there are other social or other concerns, please include it here and
attach any information necessary.
Kinder
grades
4th Grade
5th-7th Grades *
(Early Bird)
(Early Bird)
$500
$525
$700
$725
$800
$800
$825
$825
$950
-
$975
-
*After grade 4, all students and parents must join the Temple
To get the Early Bird price registration must be turned in by August 14, 2015
Childs Name___________________________
Grade____
@ $ _________
Childs Name___________________________
Grade____
@ $_________
Grade____
@ $ _________
= $ _________
To be paid as follows:
_____
Plan A
______ Plan B
25 % with Registration
25 % by September 27, 2015
25 % by November 8, 2015
25 % by December 15, 2015
If you need further financial assistance please contact Mindy Sherry Director of Youth and Family
Engagement b,y email at educator@uniontemple.org or by telephone at (718)638-7600.
Parent Signature__________________________________________
Date: ___________
___________________
Parent Signature
_________
Date
Date _____
I would like to be on the First Friday Family Shabbat Parent Committee. This group will help advertise
the First Family Shabbats, and create themes and decorations for the Shabbat dinners.
I have a SKILL/TALENT that I would be happy to share with the Religious School. For example: Have you
recently visited Israel and would be willing to talk to your childs class?
Do you play a musical instrument? Do you love to cook and would be happy to assist a teacher in a cooking project? Are
you an artist?
My skill/talent is:
Name____________________________________
Phone Number__________________________
Email Address_____________________________
My child__________________________________
will be in
grade.
My child__________________________________
will be in
grade.
My child__________________________________
will be in
grade.