Mitzvah Secular Sunday School - Enrollment Form - Form - The Secular Jewish Circle of Puget Sound

Referral Information

Were you referred by a currently enrolled family? Who should we thank?

Student Information

* How many students are you enrolling?

* Given Name

Preferred Name (if different)

* Surname

* Preferred Pronouns

* Birthdate

* Grade Level

* Residential Address

Cell Phone

Email Address

Please list all allergies to foods, plants, medications, etc:

Please make sure to include: Severity, type of reaction, and methods of exposure to avoid (ex: inhaled, ingested, physical contact).

Does this student use an Epi-Pen?

NoYes, and my child carries it with them.Yes, and we can furnish one for school staff to keep on-hand for them in case my child needs it.

Please list all medications this student is taking:

Please specify if each medication is taken at home or carried with them.

Does this student have any disabilities that staff should know about?

Does this student need any accommodations?

Is there anything else you'd like us to know about this student?

Emergency Contacts

Primary Emergency Contact
It is strongly recommended that this be the student's legal guardian.

* Full Name

* Relationship to student(s)

* Email Address

* Cell Phone

Work Phone (if different)

* This person can be contacted regarding:

Picking up student(s) from schoolSchedule changesInvoices and paymentsEmergencies

Secondary Emergency Contact

* Full Name

* Relationship to student(s)

* Email Address

* Cell Phone

Work Phone (if different)

* This person can be contacted regarding:

Picking up student(s) from schoolSchedule changesInvoices and paymentsEmergencies

Tertiary Emergency Contact

* Full Name

* Relationship to student(s)

* Email Address

* Cell Phone

Work Phone (if different)

* This person can be contacted regarding:

Picking up student(s) from schoolSchedule changesInvoices and paymentsEmergencies

Tuition Information

This information is used to calculate the total tuition for which you will be invoiced.

Tuition Rates*

• $495* per student enrolled in:

• Kitah Keff (Pre-K)

• $995* per student enrolled in:

• Kitah Gan (K & 1st grade)

• Kitah Alef (2nd & 3rd grade)

• Kitah Bet (4th & 5th grade)

• Kitah Gimel (6th & 7th grade

• $1,195* per student enrolled in:

• B Mitzvah Program

I will require financial assistance.

NoYesNo student turned away: SJC will never turn away families who are unable to pay the suggested amount.

* Please select the level of financial assistance you require:

Our Treasurer will email you prior to invoicing.

I am willing to donate an extra $100 to become a Benefactor Member.

I am willing to donate an extra $100 to become a Benefactor Member.Give the gift of education: Any additional funds donated beyond the suggested amount will be used to fund scholarships for students who cannot afford the full suggested amount, but wish to enroll/remain enrolled.

I plan to have all or a portion of my payment matched via my employer's charitable giving program.

I plan to have all or a portion of my payment matched via my employer's charitable giving program.This let's us know to keep an eye out for a check from your employer.

Consents

I/We give permission for my/our child(ren) to receive basic first aid while attending Mitzvah Secular Sunday School. I/We have informed Mitzvah Secular Sunday School staff of all my/our child(ren)'s known medical conditions and medications. I/We consent to emergency medical treatment being provided to my/our child(ren) by a licensed emergency medical team (including transport by ambulance or other emergency vehicle) when I/we cannot be reached and it is deemed immediately necessary by Mitzvah Secular Sunday School staff.

* By checking this box, I/we consent to the above Medical Release.

By checking this box, I/we consent to the above Medical Release.

I/We give permission for my/our child(ren) to attend Mitzvah Secular Sunday School field trips, and understand that transport may be provided via private vehicles (of staff, parents of existing students, or chaperones), public transit (metro bus, streetcar or light rail) or walking. Parents will always receive at least two weeks advance notice of field trips.

By checking this box, I/we consent to the above Field Trip Authorization.

I/We authorize Mitzvah Secular Sunday School to take and store photographs or video of my child(ren) while enrolled for use on the Secular Jewish Circle of Puget Sound official website and/or marketing materials.

By checking this box, I/we consent to the above Photography/Video Authorization.

By checking this box, I/we consent to the above Photography/Video Authorization.This is optional; you are opted out automatically unless you check this box.

Attestations

* By checking this box, I attest that all information furnished in this enrollment form is true and accurate to the best of my knowledge.

By checking this box, I attest that all information furnished in this enrollment form is true and accurate to the best of my knowledge.

* I understand that checking this box constitutes a legal signature.

I understand that checking this box constitutes a legal signature.