Pre B-Mitzvah Education Registration 2020/21

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Donate

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

Cell Phone

Home 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

Does this student have a sibling who will also attend Cool Shul's Pre B-Mitzvah program? If so, please list to the right.

Sibling First Name

Grade

Media Permission

Media PermissionPlease check this box if you give permission for images of your child to be used on our website, in advertising, and on 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 add more. We have reduced the tuition for this program for partners 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 monthly at $100 per month per family (or a one-time annual donation of $1200). If you choose this option, you will be able to divide it up into 12 payments if you would like to donate monthly.

Thank you so much for supporting our little (but growing!) community!!

If you are or would like to become a monthly/annual donor: Tuition for this program is reduced to $825.00 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 give you savings on Holy Days tickets and other events as well. If you are or want to become a donor at this level, please enter $825.00 per child below to pay for this program and enter the annual donation amount (you will be able to divide it into 12 monthly payments) below. 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 $1325.00 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 $1325.00 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 Donation Amount

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