The Polsky School Enrollment Form

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).