Gesher Registration 2021-22 - Form - Congregation Shaarei Shamayim

The first half of tuition is due September 1 and the second half is due January 1. You will have the option to pay in monthly installments.

Please note: To enroll your child(ren) in Gesher you are required to be a member of Congregation Shaarei Shamayim. Please submit your 2021-2022 membership forms prior to registering for Gesher. Please contact Joy Zotalis with any questions at 257-2944 or office@shamayim.org.

FAMILY INFORMATION

* New / Returning Family

* Parent/Guardian 1 First Name

* Parent/Guardian 1 Last Name

Home Phone

* Cell Phone

Work Phone

* Email

Parent/Guardian 2 First Name

Parent/Guardian 2 Last Name

Home Phone (if different)

Cell Phone

Work Phone

* Health Insurance Company

* Policy #

* Name and Phone Number of Student Primary Physician

* Emergency Contact Information

Please provide the name and number of a local friend or family member who can be contacted in case of an emergency (if parent/guardian is unreachable).

STUDENT INFORMATION

* Student #1 First Name

* Student #1 Last Name

* Grade

* Date of Birth

MM/DD/YYYY

Pronouns (optional)

Allergies or medical conditions

Please provide any additional information about your child regarding learning, social, emotional, or behavioral issues that will help us offer the best possible school experience:

If no other children skip to the next section

Student #2 First Name

Student #2 Last Name

Grade

Date of Birth

MM/DD/YYYY

Pronouns (optional)

Allergies or medical conditions

Please provide any additional information about your child regarding learning, social, emotional, or behavioral issues that will help us offer the best possible school experience:

If no other children skip to the next section

Student #3 First Name

Student #3 Last name

Grade

Date of Birth

MM/DD/YYYY

Pronouns (optional)

Allergies and Medical Conditions

Please provide any additional information about your child regarding learning, social, emotional, or behavioral issues that will help us offer the best possible school experience:

Is there anything about your child(ren) you would like to share with Rabbi Laurie (e.g., divorce, custody arrangements, ongoing illness, recent death in the family)?

PARENTAL CONSENT

* Medical Emergency Release: I hereby give my permission to the physician or medical professional selected by staff to secure proper treatment for my child, which I understand might include hospitalization, injections, anesthesia, or surgery. I recognize that I will be responsible for any costs incurred for this treatment.

Please Select OneYesNo (If selected, you will be required to be on premise for all Gesher sessions and programs your child(ren) attends.)

* Transportation Release: I understand that any volunteer driver who transports my child will have certified that s/he has auto insurance which will cover any injuries to Shaarei Shamayim students who s/he is driving, if there should be an accident; has a valid driver's license which is not currently suspended or revoked; does not have a health condition which will impair his or her ability to drive safely; will use an automobile for driving Shaarei Shamayim students which is in safe mechanical condition; will promptly notify the Gesher Director if s/he is no longer able to certify any of the above four items. I hereby permit my child to attend all Congregation Shaarei Shamayim Gesher school field trips.

Please Select OneYesNo (If selected, you will be responsible for transporting your child for all field trips and unable to ride share.)

If you are willing to drive students for occasional field trips, please check the below boxes:

I have auto insurance which will cover any injuries to Shaarei Shamayim Gesher students whom I am driving, should there be an accident.I have a valid driver's license which is not currently suspended or revoked.I do not have a health condition which will impair my ability to drive safely.I will use an automobile for driving Shaarei Shamayim Gesher students which is in safe mechanical condition.I will promptly notify the Gesher Director if I am no longer able to certify any of the above four items.

* Is this information correct to the best of your knowledge?

Please Select OneYesNo

Should a place on the Children's Education committee become available, would you be interested in joining?

YesNoMaybe

Would you like to be a class parent? Duties include arranging snack, welcoming new parents to the community, and being a liaison to the teachers.

YesNoMaybe

Would you like to occasionally help plan holiday celebrations or do other discrete tasks?

YesNoMaybe

May we include your contact information in the Gesher roster?

YesNo

PAYMENT INFORMATION

Key to Grades
Aleph: Kindergarten | Bet: 1st grade | Gimmel: 2nd grade | Daled: 3rd grade | Hay: 4th grade | Vav: 5th grade | Zion: 6th grade | Chet: 7th grade

Tuition
Gan, Aleph, Bet, Gimmel: $350 (Sunday only)
Daled, Hay, Vav, Zion: $575 (Sunday and tutoring)
Chet: $350 (Sunday only)
Chet: $575 (Sunday and tutoring)
Partial Year: $125 (Pre-approval required)
Tutoring only: $500 (Must be pre-approved by Rabbi Laurie)

*After August 31, a $25 late fee will be added onto to each enrollment (reflected in the total).

Families with more than one child can select the multi-child discount of $75 for each additional child up to $150.

For scholarship information please contact Rabbi Laurie. If requesting, select 'bill to account' when registering.

* Enter number of children at each rate

Gan Aleph Bet Gimmel (Sunday only)

Daled Hay Vav Zion (Sunday and tutoring)

Chet (Sunday only)

Chet (Sunday and tutoring)

Tutoring Only (pre-approval required)

Multiple Child Discount ($75) - Select "1" for 2 children, or "2" for 3 or more.

Partial Year (pre-approval required)

Total

Upon hitting "Submit" you will be taken to a payment page where you can enter your credit/banking information to make a payment, set up a recurring payment, or select payment by check.