Temple Beit Torah Religious School

Registration Form 2009-2010

522 E. Madison St.

Colorado Springs, CO 80907

Y Please fill out a SEPARATE form for EACH child Y

child's name birthdate (m/d/yr) public school grade this year school district
family name father's name mother's name
address city state zip
home phone father's CELL phone mother's CELL phone has the child been consecrated?
state class(es) in which child should be enrolled in fall 2009
(pre-k thru 7) Judaic Studies grade (grades 1 thru 6) sunday hebrew grade
PLEASE CHECK ANY CONDITIONS EXPERIENCED BY YOUR CHILD, KNOWLEDGE OF WHICH WILL ENABLE THE SCHOOL TO HELP HIM/HER HAVE A MORE POSITIVE EXPERIENCE

Food allergies
Vision Hearing Allergy Special Educational Needs
Physician's name Phone number
Dentist's Name Phone number
Emergency contact (other than parent/guardian) Phone number
Parent(s) Email Address(es):

I/We ____________________________, Parent's / Guardian of ______________________

Name(s) Child's name

authorize the Temple Beit Torah Religious School staff to seek emergency medical care for my child when deemed necessary. All medical costs shall be the responsibility of the parent(s) and/or guardian(s) mentioned above.

A copy of this authorization shall be given the same force and effect as the original.

_____________________________ _________________________________________

Parent name (please print ) Signature