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

Referral Information

Were you referred by another family? What is their name?

Student Information

* How many students are you enrolling?

Please complete the below form for each student enrolling, as well as three emergency contacts for them.

* 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, methods of exposure to avoid (ex: inhaled, ingested, physical contact), and any medications they are taking to prevent/treat the allergy(s).

Does this student use an Epi-Pen?

NoYes, and my child carries it with themYes, 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

Emergency Contact #2

* 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

Emergency Contact #3

* 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.

No household turned away: SJC does not turn away students who are unable to pay the full tuition amount. If you need to request a payment plan, lower rate, or even a full waiver, for tuition because of temporary hardship, please enroll anyway and connect with our Treasurer to explain your situation/needs so we can adjust your invoice.

Tuition Rates

$1,195 per student enrolled in:

> Kitah Gimel (6th & 7th grade)

> B Mitzvah Program

$995 per student enrolled in:

> Kitah Gan (K & 1st grade)
> Kitah Alef (2nd & 3rd grade)
> Kitah Bet (4th & 5th grade)

$495 per student enrolled in:

> Kitah Keff (Pre-K)

Additional Benefactor Donation

Give the gift of community: Any additional funds paid beyond the tuition total will be used to cover the tuitions of members whose households cannot afford the full amount due to hardship, 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.

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.