Post Bnei- Mitzvah Registration 2020/21

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REGISTRATION INFORMATION

Student's Last Name

Student's First Name

Student's Birthdate

Name of School

Grade in 2020-21

Student's Primary Address

City

Zip Code

Parent #1 Last Name

First Name

Parent E-mail

Home Phone

Cell Phone

Parent #2 Last Name

First Name

Parent Email

Home Phone

Cell Phone

Emergeny Contact Last Name

Emergency Contact First Name

Emergency Contact's Relationship to the Child

Emergency Contact Address

Emergency Contact Cell Phone Number

Choose Class Section - Middle or High School

Media Permission

Media PermissionPlease check this box if you give permission for images of your child to be used on our website, advertising and social media.

PAYMENT INFORMATION

Cool Shul is a 501c3 non-profit and only through our partnership program will Cool Shul be able to continue to provide the services we do and continue to add more. We have reduced the tuition for this program to encourage families to participate in our partnership program and donate annually or monthly. Our goal is to have 50 families raise their hands to be our partners by donating annually or monthly in an amount of $100 per month. To make an annual donation of $100 per month, or $1200 per year, please enter that amount in the correct box below. You will be able to spread that payment out over 12 months. If you already filled out the separate Partnership form, you can skip it here and just fill in the reduced tuition amount. Thank you!

If you are or would like to become a monthly/annual donor: Tuition for this program is reduced to $400 per child if you also agree to a monthly donation of $100 (or more) per month or an annual donation of $1200 (or more) per year. Becoming a part of this partnership program will also lead to savings on Holy Days tickets and other events as well. If you want to become a donor at this level, please enter $400 per child below to pay for this program and enter the annual donation below. You will be able to divide it over 12 months. If you already filled out the separate partnership form or have an automatic partnership payment, you may leave the donation box empty. Please do not choose this option if you are not signing up to be one of our monthly donors.

If you would prefer not to become a monthly or annual donor: The cost of this program is $700 per child if you are not a monthly or annual donor at the level described above. If you are not able to become a monthly or annual donor at the above level, please enter $700 per child below.

Please contact our Treasurer if you would need to make other financial arrangements. We won't ever turn a student away because of finances!

* Tuition Payment

Annual Partner Amount 0f $1200 if this option is chosen

MEDICAL INFORMATION

Child's Physician

Physician's Phone Number

Child's known allergies

Any known medical conditions you wish for the teaching staff to be aware of

Medical authorization

Please check the box to authorize the Cool Shul educators or any adult volunteers to make available medical care if such care is indicated. It is understood that a conscientious effort will be made to notify me, my spouse, or designated emergency contact before such action is taken. It is further understood that every effort will be made to contact my child's physician prior to any treatment. I give permission for my child to receive proper medical treatment by any doctor, nurse, paramedic or hospital staff licensed by the State of California.

Mon, March 8 2021
24 Adar 5781

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Mon, March 8 2021 24 Adar 5781