RS Registration 25-26 | Temple Shaarei Shalom

Religious School Registration CONTINUING STUDENTS Form 2025-2026

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Student #1 Name(Required)

First Last

Student #1 Birthdate MM/DD/YY(Required)

Student #1 Private/Public School Grade Upcoming Year(Required)

Student #1 Name of School(Required)

Student #1 Gender or Preferred Gender(Required)

Does student #1 have an IEP or 504? If so please provide a copy.(Required)

Student #1 Health issues/concerns/medications/ALLERGIES that may affect student while at TSS?(Required)

Hebrew Name (if known)

Student #1 Email address

Student #1 Cell Phone Number

Student #1 List & Describe Medication that we should be aware of. Include time of day they are administered. Please write "None" if not applicable(Required)

This section for Grade 4-7 for the mid-week day of choice

First Choice: please select from drop down

Second Choice : please select from drop down

Third Choice: please select from drop down

Fourth Choice: please select from drop down

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Student #2 Name

First Last

Student #2 Birthdate MM/DD/YY

Student #2 Private/Public School Grade Upcoming Year

Student #2 Name of School

Student #2 Gender or Preferred Gender

Does student #2 have an IEP or 504? If so please provide a copy.

Student #2 Health issues/concerns/medications/ALLERGIES that may affect student while at TSS?

Hebrew Name (if known)

Student #2 Email address

Student #2 Cell Phone Number

Student #2 List & Describe Medication that we should be aware of. Include time of day they are administered.

This section for Grade 4-7 for the mid-week day of choice

First Choice: please select from drop down

Second Choice: please select from drop down

Third Choice: please select from drop down

Fourth Choice: please select from drop down

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Student #3 Name

First Last

Student #3 Birthdate MM/DD/YY

Student #3 Private/Public School Grade Upcoming Year

Student #3 Name of School

Student #3 Gender or Preferred Gender

Does student #3 have an IEP or 504? If so please provide a copy.

Student #3 Health issues/concerns/medications/ALLERGIES that may affect student while at TSS?

Hebrew Name (if known)

Student #3 Email address

Student #3 Cell Phone Number

Student #3 List & Describe Medication that we should be aware of. Include time of day they are administered.

This section for Grade 4-7 for the mid-week day of choice

First Choice: please select from drop down

Second Choice: please select from drop down

Third Choice: please select from drop down

Fourth Choice: please select from drop down

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Parent/Guardian #1 Name(Required)

First Last

Parent/Guardian #1 Personal Email Address(Required)

Enter Email Confirm Email

Parent/Guardian #1 Personal Cell Phone(Required)

Parent/Guardian #1 Home Address(Required)

Street Address Address Line 2 City State ZIP Code

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Parent/Guardian #2 Name

First Last

Parent/Guardian #2 Personal Email Address

Enter Email Confirm Email

Parent/Guardian #2 Personal Cell Phone

Parent/Guardian #2 Address (if different from parent #1)

Street Address Address Line 2 City State ZIP Code

PLEASE PROVIDE TWO NAMES THAT WE CAN CONTACT IN AN EMERGENCY IF WE CANNOT REACH THE PARENTS/GUARDIANS listed above: Full Name/Relation/Cell phone

PLEASE NOTE: We will not release students to anyone other than those that appear on this form without your express written consent. Please send a note with your student, or send an email to arrange alternate pickup arrangements.

Emergency Contact 1 Full Name(Required)

Emergency Contact 1 Phone(Required)

Emergency Contact 1 Relation (NOT PARENT)(Required)

Emergency Contact 2 Full Name(Required)

Emergency Contact 2 Phone(Required)

Emergency Contact 2 Relation (NOT PARENT)(Required)

MEDIA RELEASE/PERMISSIONS: I hereby give permission to Temple Shaarei Shalom to take and use still photos and video of my child/ren for appropriate media coverage including the TSS website, Facebook, and Instagram pages and for the Jewish Federation of the Palm Beaches and other Jewish agencies.(Required)

YES

HEALTH & SAFETY RELEASE: I hereby give permission for the minor child/ren to attend any school activity sponsored by Temple Shaarei Shalom Religious School. I hereby do release and hold harmless Temple Shaarei Shalom and its trustees, agents, officers and employees against loss (including reasonable attorney’s fees) from any and all claims, or causes of action of any kind or nature that may be brought by or on behalf of the said minor child/ren or by me arising out of any and all know or unknown, foreseen and unforeseen bodily or personal injuries, damages to property and consequences thereof, which may be sustained by the minor or by me, arising out of or in connection with the minor child/ren’s participation in this activity, except such liability or claim of liability as may result from gross negligence on the part of Temple Shaarei Shalom. If the minor child/ren should suffer an injury or illness during school time, or on any school related trip, I authorize the employees of Temple Shaarei Shalom to use their discretion to transport or to have the minor child/ren transported to any medical facility and hereby give consent in my absence to have the minor child/ren treated at any medical facility, and I take full responsibility for that action.(Required)

YES

By Signing here, I agree that I will pay the Curriculum Supplies Fee PRIOR to the start of the Religious School Year or an agreed upon payment plan and that all information is correct. Parent Signature:(Required)