Rosenbloom Religious School 2019-2020 Registration

Welcome!

Thank you for your interest in Rosenbloom Religious School! Please complete the registration form below, including a $100 deposit per student payable by credit card. If you prefer to pay by check or have your synagogue account billed, please complete the form, then print and return to:

Rosenbloom Religious School
8100 Stevenson Road
Baltimore, MD 21208

If you have any questions or concerns, please contact us via phone at (410) 486-8641 or via email at rosenbloom@chizukamuno.org.

Student #1 Name*

First Last

Student #1 Hebrew Name

First

Student #1 Birthday*

MM

DD

YYYY

Student #1 Gender*

Male
Female

Student #1 Day School*

Student #1 Program Selection*

Student #1 Allergy and Dietary Restrictions*

No, this student does not have any allergies or dietary restrictions.
Yes, this student has allergies or dietary restrictions.

Student #1 Allergy and Dietary Restrictions Detail*

Please use the space below to describe, as fully as possible, your student's allergies and dietary restrictions.

Student #1 Learning or Medical Concerns*

No, this student does not have any learning or medical concerns.
Yes, this student has a special learning or medical concern.

Student #1 Learning or Medical Concerns Detail*

Please use the space below to describe, as fully as possible, any learning or medical issues that this student has that may affect their classroom experience, cause you any concern, or that their teacher should be aware of.

Student #1 Medications*

No, this student does not take any medications.
Yes, this student takes medication of any kind.

Student #1 Medications Detail*

Please use the space below to describe, as fully as possible, the medications your student takes, the conditions the medication is for, and how often they take the medication.

Are you interested in enrolling another student today?*

Yes
No

Student #2 Name*

First Last

Student #2 Hebrew Name

First

Student #2 Birthday*

MM

DD

YYYY

Student #2 Gender*

Male
Female

Student #2 Day School*

Student #2 Program Selection*

Student #2 Allergy and Dietary Restrictions*

No, this student does not have any allergies or dietary restrictions.
Yes, this student has allergies or dietary restrictions.

Student #2 Allergy and Dietary Restrictions Detail*

Please use the space below to describe, as fully as possible, your student's allergies and dietary restrictions.

Student #2 Learning or Medical Concerns*

No, this student does not have any learning or medical concerns.
Yes, this student has a special learning or medical concern.

Student #2 Learning or Medical Concerns Detail*

Please use the space below to describe, as fully as possible, any learning or medical issues that this student has that may affect their classroom experience, cause you any concern, or that their teacher should be aware of.

Student #2 Medications*

No, this student does not take any medications.
Yes, this student takes medication of any kind.

Student #2 Medications Detail*

Please use the space below to describe, as fully as possible, the medications your student takes, the conditions the medication is for, and how often they take the medication.

Are you interested in enrolling another student today?*

Yes
No

Student #3 Name*

First Last

Student #3 Hebrew Name

First

Student #3 Birthday*

MM

DD

YYYY

Student #3 Gender*

Male
Female

Student #3 Day School*

Student #3 Program Selection*

Student #3 Allergy and Dietary Restrictions*

No, this student does not have any allergies or dietary restrictions.
Yes, this student has allergies or dietary restrictions.

Student #3 Allergy and Dietary Restrictions Detail*

Please use the space below to describe, as fully as possible, your student's allergies and dietary restrictions.

Student #3 Learning or Medical Concerns*

No, this student does not have any learning or medical concerns.
Yes, this student has a special learning or medical concern.

Student #3 Learning or Medical Concerns Detail*

Please use the space below to describe, as fully as possible, any learning or medical issues that this student has that may affect their classroom experience, cause you any concern, or that their teacher should be aware of.

Student #3 Medications*

No, this student does not take any medications.
Yes, this student takes medication of any kind.

Student #3 Medications Detail*

Please use the space below to describe, as fully as possible, the medications your student takes, the conditions the medication is for, and how often they take the medication.

Are you interested in enrolling another student today?*

Yes
No

Student #4 Name*

First Last

Student #4 Hebrew Name

First

Student #4 Birthday*

MM

DD

YYYY

Student #4 Gender*

Male
Female

Student #4 Day School*

Student #4 Program Selection*

Student #4 Allergy and Dietary Restrictions*

No, this student does not have any allergies or dietary restrictions.
Yes, this student has allergies or dietary restrictions.

Student #4 Allergy and Dietary Restrictions Detail*

Please use the space below to describe, as fully as possible, your student's allergies and dietary restrictions.

Student #4 Learning or Medical Concerns*

No, this student does not have any learning or medical concerns.
Yes, this student has a special learning or medical concern.

Student #4 Learning or Medical Concerns Detail*

Please use the space below to describe, as fully as possible, any learning or medical issues that this student has that may affect their classroom experience, cause you any concern, or that their teacher should be aware of.

Student #4 Medications*

No, this student does not take any medications.
Yes, this student takes medication of any kind.

Student #4 Medications Detail*

Please use the space below to describe, as fully as possible, the medications your student takes, the conditions the medication is for, and how often they take the medication.

Primary Mailing Address*

This is the address we will use for correspondence.

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Do you have a second mailing address?*

Yes
No

Address #2*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Home Phone*

What is your current synagogue affiliation status?*

Which synagogue are you affiliated with?*

Would you like someone from Chizuk Amuno to contact you regarding membership?*

Yes, please contact me regarding membership.
No thanks, I am not interested in membership at this time.

Do you have any children enrolled in Chizuk Amuno schools that you are not enrolling in Rosenbloom Religious School today?*

Yes
No

Please indicate in which schools you have other children enrolled.*

Goldsmith Early Childhood Center
Krieger Schechter Day School
Achshav or Netivon High School

Parent #1 Name*

First Last

Parent #1 Email*

Parent #1 Cell Phone*

Parent #1 Work Phone

Parent #2 Name

First Last

Parent #2 Email

Parent #2 Cell Phone

Parent #2 Work Phone

Emergency Contact*

First Last

Emergency Contact Phone*

Photo Release Authorization*

I hereby authorize Chizuk Amuno Congregation to use print and digital pictures and videos of my child(ren), taken at Chizuk Amuno Congregation events, in print and digital publicity and marketing for Chizuk Amuno Congregation and Rosenbloom Religious School. I understand that my child's full name will NEVER appear next to his or her picture and the pictures will be used exclusively to promote Chizuk Amuno Congregation and Rosenbloom Religious School or for educational materials.

Yes, I authorize the use of photos.
No, I do not authorize the use of photos.

Off-Site Field Trip Authorization*

I hereby grant my permission for my child(ren) to attend any programs or field trips off-site during regular Rosenbloom Religious School hours and to take any transportation required to attend these trips. I understand that I will be notified in advance of any off-site programs or field trips applicable to my child(ren) so that I will know his/her whereabouts at all times.

Yes, I give permission for off-site field trips.
No, I do not give permission for off-site field trips.

Total Amount Due Today

$0.00

Electronic Signature*

By entering my name, I certify that all information on this registration form is correct to the best of my knowledge and that I am making a non-refundable deposit and a commitment to Rosenbloom Religious School for the 2019-2020 academic year.

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Rosenbloom Religious School 2019-2020 Registration

Welcome!