Jewish Community School
1008 W. Water Street
Elmira, NY 14905
(607) 734-8122
REGISTRATION for 5776 / 2015–2016
PART 1Family Information
First Parent / Second Parent
Last Name / First Name / Last Name / First Name
Home Address / City, State, ZIP / Home Address / City, State, ZIP
Home Phone / Home Phone
Work Phone / Work Phone
Mobile Phone/Pager / Mobile Phone/Pager
Email / Email
Please provide at least one email address. We distribute most parent information by email.
Emergency Information
Emergency Contacts
If you cannot reach a parent, please call:
1 / Name / Phone
2 / Name / Phone
3 / Name / Phone
Medical Information
Physician’s Name / Phone
Insurance Company / Policy Number
Permissions
I give permission to the Jewish Community School (JCS) to obtain emergency medical care for my child(ren) in the event that none of the people listed can be reached.
o Yes o No
I give permission to the JCS to take my child(ren) on local, walking, field trips. These may be spur-of-the-moment trips that will not affect pickup or drop off. If trips require changes in scheduling or special transportation arrangements, I will be notified ahead of time.
o Yes o No
I give permission to JCS to take photographs of my child for use on the community’s website and any other printed or electronic publication.
o Yes o No
Signature / Date
PART 2
Student Information
Parents’ Names
Please fill out one section below for each student.
First Student
Student’s Last Name / First Name
Hebrew Name / Date of Birth / Religious School Grade
Public School Name / Public School Grade
Lives with o Mother o Father o Both
Special Information about the student that the school must know (allergies, conditions, medications, learning needs, etc.):
Second Student
Student’s Last Name / First Name
Hebrew Name / Date of Birth / Religious School Grade
Public School Name / Public School Grade
Lives with o Mother o Father o Both
Special Information about the student that the school must know (allergies, conditions, medications, learning needs, etc.):
PART 3
Fee Worksheet
5776 / 2015–2016
Parents’ Names
Student’s Name / Grade
Student’s Name / Grade
Student’s Name / Grade
Student’s Name / Grade
Religious School Tuition
Grade / Number Enrolled / Tuition / Total
Pre-Kindergarten, Kindergarten, Grade 1 / × / $420 / = / $
Grades 2–6 / × / $490 / = / $
Grades 7–10 / × / $420 / = / $
Total Tuition / $
Volunteer Service
o I/we will volunteer six hours per family
Please choose from the following:
o Sukkot Celebration – Oct. 4
o Hanukkah Party – Dec. 13
o Tu Bishvat Seder – Jan. 24
o Purim Carnival – Mar. 20
o Model Seder – April 17 (PK-2 only) / OR o I/we cannot volunteer and will pay a fee of $75 / $
TOTAL ENCLOSED / $
Please complete all three pages and sign page 1.
Please make your check payable to: Jewish Community School.
TERMS AND CONDITIONS
Registration required: All students must be registered. A student not formally enrolled may attend for one session.
Payment: Tuition is due in full before the first day of school. If you are unable to pay in full prior to the opening of school, please call our office to make arrangements.
Membership: Families must be members in good standing of Congregation Kol Ami.
Withdrawal: A pro-rata refund will be issued for withdrawal prior to November 15, 2014. On or after November 15, 2014, no refunds will be issued.
Return forms and payment to
Jewish Community School
1008 W. Water Street
Elmira, NY 14905
(607) 734-8122
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