Fierverker Jewish Learning Community (FJLC) Registration 2023-2024

* Date

Directions:
Please review and COMPLETE A FORM FOR EACH CHILD. The below information will be shared with your child's teacher to help enrich your child's Religious School experience.

Please advise the Fierverker Jewish Learning Community (FJLC) Principal of any changes during the school year.

Student Information

* Student's Last Name

* Student's First Name

Student's Hebrew Name

* Grade as of September

* Gender

* Birthday

Student's Email if applicable

* Public/Private/Day School

* Name of school student attends.

Parent/Guardian Information

* Parent/Guardian First Name

* Parent/Guardian Last Name

* Email Address

* Address Line 1

(Apt, Suite, etc.)

* City

* State

* Zip

* Mobile Phone (ex. 123-456-7890)

Other Phone (ex. 123-456-7890)

Parent/Guardian First Name

Parent/Guardian Last Name

Email Address

Address Line 1

(Apt, Suite, etc.)

City

State

Zip

Mobile Phone (ex. 123-456-7890)

Other Phone Number (ex. 123-456-7890)

If the student lives in two households, please indicate the parent/guardian name, address, email, and telephone number below.

List student's sibling (s).

First Name

Last Name

Birthday

First Name

Last Name

Birthday

First Name

Last Name

Birthday

Student Background
Please type in all information in the text boxes provided below.

List student's experiences at previous Religious Schools other than Beth El (school/grade (s).

How does your child learn best?

What does the student enjoy most about Religious School?

What are the student's hobbies/interests?

* Does the student have an IEP or 504 Plan? If so, please share with the principal. (Please answer YES or NO)

Health and other information
Please type in all information in the text boxes provided below.

* List any known medical conditions. (Please answer NONE if applies)

* List any medications taken regularly. (Please answer NONE if applies)

* Date of last TETANUS immunization.

* List any known allergies (please answer NONE if applies).

* List any known reactions to allergens (please answer NONE if applies).

* Does the student have an epi-pen? (Please answer NONE if applies)

* Upload immunization records.

Insurance Information
Please type in all information in the text boxes provided below.

* Health Insurance Carrier

* Policy Number/ID/Group #

* Primary Doctor & Phone Number

* Upload Insurance Card FRONT.

* Upload Insurance Card BACK.

Emergency Contact Information
If I/we cannot be reached in case of a serious injury or illness please contact the person listed below (this is an emergency contact and should NOT be a parent).

* First Name (Emergency Contact)

* Last Name

* Relationship to student (ex. aunt, uncle, friend of family etc.).

* Phone number (ex. 123-456-7890)

Permissions and Authorizations
Please type in all information in the text boxes provided below.

* Please list all people (in addition to parents/guardians) that can pick up your child from school. Please include carpool information as well (please answer NONE if applicable).

* Will anyone other than the parents/guardians listed above pick up your student from Religious School? (please answer YES or NO).

* Will you allow photographs and/or videos of your student to be included in Beth El social media and publicity (please answer YES or NO)?

* Do you want to be a part of a FJLC directory (please answer YES or NO)?

* My TYPED NAME below certifies that the above information is correct for the current school year.

Thank you. We appreciate you taking the time to fill out your child's registration. You will receive a confirmation email once the form is complete.

Tue, May 30 2023 10 Sivan 5783