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Pre-K Class Registration 2017-18

This form is for registering students for pre-K class at Am Shalom. The class will meet 9 times from 10:00 - 11:15 am on Sunday morning throughout the year. The cost is $180/child. The class is for kids entering Kindergarten in the fall of 2018
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Are you a member at Am Shalom? This is for informational purposes only(*)

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How many children are pre-K class at Am Shalom?(*)
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If registering more than 2, please email us after submission at school@amshalom.com

Parent 1 First Name(*)
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Parent 1 Last Name(*)
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Parent 2 First Name
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Parent 2 Last
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Do both parents live at the same address?
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Street Address(*)
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City(*)
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State(*)
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Zip Code(*)
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E-mail Address(*)
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Home Phone Number(*)
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Cell Phone Number(*)
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Work Phone Number
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2nd Parent
Please select one of the following regarding communication with second parent

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Street Address
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City
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State
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Zip Code
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Home Phone Number
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Parent 2 E-mail Address
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Parent 2 Work Phone Number
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Parent 2 Cell Phone Number
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Child 1 First Name(*)
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Child 1 Last Name(*)
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Nickname
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Gender(*)
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Birth Date(*)
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Name of Preschool
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Does this child have any allergies and/or intolerances?

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Please check all that apply

Please list any other allergies and/or intolerances here
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Does this child carry an Epipen?(*)
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Please tell us a little bit more about your child: What does your child like? What are their interests? Talents? What can you tell us about them personally that can best help us improve their classroom experience? All information is appreciated.
(*)
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2nd Child
Child 2 First Name(*)
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Child 2 Last Name(*)
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Nickname
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Gender(*)
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Birth Date(*)
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Name of Preschool
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Does this child have any allergies and/or intolerances?

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Please check all that apply

Please list any other allergies and/or intolerances here
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Does this child carry an Epipen?(*)
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(*)
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Emergency Contact Other Than A Parent:
In the event of illness/emergency we will make every effort to reach parents first. If we cannot reach parents, than we will call this emergency contact.
Name of Emergency Contact (other than parent)(*)
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Relationship to Children(*)
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Emergency Contact Telephone Number(*)
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Physician's Name(*)
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Physician's Phone Number(*)
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On occasion classes may leave the building. If students take a field trip where they leave the immediate area, are transported by bus, or have hours different from the norm, I understand that I will be notified by a separate letter and such trips would require a permission slip.
I give permission for my child(ren) to leave the building for outdoor activities within close walking distance, and I understand that every precaution will be taken with his/her care and transportation. I will assume any liability for any injury incurred.
If I cannot be reached in case of an emergency, I give officials permission to render any emergency care deemed necessary.
Occasionally Am Shalom staff take pictures or make videos of our school programs. We use these to decorate our halls and classrooms, on our Totem display units, and to publicize school and synagogue programs. Teachers may choose to distribute pictures or videos made of children in their class to the entire class to further enhance their classroom experience. We also stream our sanctuary Shabbat and holiday services in which your child might appear. I grant Am Shalom permission to record and use photographs/videos of my child(ren) in any medium for educational, promotional, or other purposes that support the mission of the congregation.
What do you hope your family will gain from religious school at Am Shalom?(*)
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Filling in your name here constitutes your virtual signature and agreement with the above(*)
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Total Amount Owed for Pre-K Class:
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Amount with 3% credit card fee if you are paying online:
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