The Polsky School Enrollment Form

If your child is entering Kindergarten or First Grade, would you be interested in being part of our Better Together program?

Find out more about Better Together here.

Yes
No

Today's Date

Student's Name*

First Last

Hebrew Name

Name

Student's Email

Enter Email Confirm Email

Grade in Fall 2021*

Name of School*

Date of Last Tetanus Shot*

Does your child have or ever been treated for:*

If you answered yes to any of the above, please explain.

Current medication(s), dosage, and reason prescribed

Do you have a second child to enroll?*

Second Child's Name

First Last

Second Child's Grade in Fall 2021

Hebrew Name

Name

Student Email

Enter Email Confirm Email

Name of School

Date of Last Tetanus Shot

Does your child have or ever been treated for:

Surgery
Serious illness
Hyperactivity
Frequent headaches
Allergies
Asthma
Seizures
Diabetes
Other

If you answered yes to any of the above, please explain.

Current medication(s), dosage, and reason prescribed

Do you have a third child to enroll?

Third Student's Name

First Last

Third Child's Grade in Fall 2021

Hebrew Name

Name

Student's Email

Enter Email Confirm Email

Name of School

Date of Last Tetanus Shot

Does your child have or ever been treated for:

Surgery
Serious illness
Hyperactivity
Frequent headaches
Allergies
Asthma
Seizures
Diabetes
Other

If you answered yes to any of the above, please explain.

Current medication(s), dosage, and reason prescribed

Do you have a fourth children to enroll?

Fourth Student's Name

First Last

Fourth Child's Grade in Fall 2021

Hebrew Name

Name

Student's Email

Enter Email Confirm Email

Name of School

Date of Last Tetanus Shot

Does your child have or ever been treated for:

Surgery
Serious illness
Hyperactivity
Frequent headaches
Allergies
Asthma
Seizures
Diabetes
Other

If you answered yes to any of the above, please explain.

Current medication(s), dosage, and reason prescribed

AUTHORIZATION TO PERMIT EMERGENCY MEDICAL CARE OR TREATMENT AND RELEASE OF INFORMATION FOR MEDIA AND OTHERWISE

Effective from September 12, 2021 through May 22 2022; we do hereby grant Congregation Beth Shalom (“CBS”), its agents, servants, and employees, the authority to direct, authorize and permit any medical care or treatment for our child(ren). while in its care. We hereby agree to assume all financial responsibility for such care or treatment on behalf of our child(ren) and to either pay the medical provider directly or to reimburse CBS, its agents, servants, and employees for any reasonable and necessary medical expenses incurred by it on behalf of our child(ren).

We also do hereby grant CBS, its agents, servants, and employees, the authority to remove our child(ren) from its facilities while in its care in the event of any emergency which, in the sole and exclusive opinion of CBS, its agents, servants, and employees, necessitates such removal. We hereby agree that CBS, its agents, servants, and employees, may transport our child(ren) to such other locations as may be deemed necessary in order to safeguard our child(ren) from the known or perceived threats or risks to their safety.

We also do hereby consent that any information or images relating to our child(ren) may be reproduced by CBS and/or the public media for use in advertising, publicity, or educational activities including, but not limited to, CBS publications and/or videos, prints, television news and websites. Furthermore, we hereby consent that such images are the property of CBS and that CBS shall have the right to sell, duplicate, reproduce in the form of advertising, or otherwise publish and make other uses of such images as CBS may desire. We agree to waive any claims we may have and release CBS, its agents, servants, and employees, from any liabilities or claims arising out of such activities.

The Family Educational Rights and Privacy Act (“FERPA”), a federal law, requires that schools, with certain exceptions, obtain my written consent prior to disclosure of personally identifiable information from my child(ren)'s educational records. With this in mind, I agree that CBS may disclose appropriately designated “directory information” by my agreement below. CBS has designated the following information as directory information: student’s name, grade level, whether they are a student in good standing, and whether and when the student has graduated.

A photocopy of this authorization shall be of the same force and effect as an original for purposes of authorizing and permitting the medical care or treatment requested for our child(ren).

I agree.

We would like the following contact information included on a Polsky School Family Roster that will be given to all PRS parents to be able to contact each other easily

Name of Parent(s)
Name of Student(s)
Home Phone
Cell Phone
Email Address
Do not include my information in the Polsky School Family Roster

Parent 1 Name*

First Last

Parent 1

Hebrew Name

Email*

Enter Email Confirm Email

Parent 1 Cell Phone*

Parent 1 Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Parent 1 Occupation

Work Phone

Parent 2 Name

First Last

Parent 2

Hebrew Name

Parent 2 Cell Phone

Parent 2 Occupation

Work Phone

Parent 2 Address

If different from above

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Health Insurance Policy

Policy #

Name of Policy Holder

Name of Family Physician

Physician's Phone

Is there any information you can give us to better facilitate your child(ren)'s education?

In order to optimize your child(ren)'s learning environment, please identify any special services s/he receives in public school such as the gifted program, learning center, remedial reading, resource room, or IEP.

Tuition for the 2021/2022 school year is nearly the same as last year, with a few changes noted below:
Kindergarten & 1st grade "Better Together": $180
Families that join Better Together get an automatic $400 scholarship
2nd grade: $590
3rd - 6th grade: $1205
7th grade: $900
8th - 9th grade: $590
10th grade: $450 (confirmation trip will be billed separately)

Tuition Amount*

Tuition Amount for Second Child*

Tuition Amount for Third Child*

Tuition Amount for Fourth Child*

Total

$0.00

Payment Information

Payment Method*

Pay by credit card or debit card
Pay by check
Submitting Scholarship Application

Please make your check payable to Congregation Beth Shalom and mail it to the synagogue office with a copy of the email receipt you will receive upon submission.

Please return your completed Scholarship application to Richard Simon along with a copy of your most recent 1040 with all schedules attached. To access the form, click here.

Would you like to add an amount to cover the credit card convenience fee?

Yes - let me add a 2.5% contribution

Additional contribution to cover the credit card convenience fee

Price: $0.00

Total

$0.00

Credit Card

American Express

Discover

MasterCard

Visa

Card Number Expiration Date Security Code Cardholder Name

Billing Information

Billing Name*

First Last

Billing Address*

Street Address City State ZIP Code

Billing Phone*

Billing Email*

Do you have any additional comments?

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The Polsky School Enrollment Form

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