4100 Sherbrooke St. W., Westmount, Quebec, H3Z 1A5 - Tel: 514•937•7058 - www.templemontreal.ca

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Birthdate (MM/DD/YYYY)

Student's Name (First and Last)

Secular School

Grade in Sept 2016: K-12

Choose the grade your child will attend

Hebrew Name, if applicable

Was this student previously enrolled in Torah School at Temple?

Gender

Street AddressCity Province (if not QC) Postal Code

Primary Phone

Secondary Phone

Primary E-mail Address (The majority of our communication is electronic, so this is vital).

Optional Second e-mail address

Child's e-mail address (if applicable)

If NO, does parent #2 want to receive information?

If YES, please provide 2nd mailing and email address here:

Does child live with both parents?

Please complete one form for each child. We believe everyone should have equal access and opportunity to participate in Torah School and Temple life. Need help? Contact rabbigreenspan@templemontreal.ca. Temple means Inclusion

1 - BASIC INFORMATION

Notes: Junior Torah School (ages 4 & 5, Pre-K and K) - 7th Grade Torah School (B'nai Mitzvah Class) - 8th/9th Grade Torah School (Combined class; Confirmation takes place at the end of Grade 9).

2 - GENERAL INFORMATION Child's Home Address

4100 Sherbrooke St. W., Westmount, Quebec, H3Z 1A5 - Tel: 514•937•7058 - www.templemontreal.ca

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Parent & Emergency Contact Information

Parent/Guardian #1's Name

Parent/Guardian #1's Cell Phone Number

Parent/Guardian #1's Work Phone Number

Parent/Guardian #2's Work Phone Number

Parent/Guardian #2's Cell Phone Number

Parent/Guardian #2's Name

3 - MEDICAL INFORMATION

Medicare Number/Expiry Date

Doctor's Name

Doctor's phone

Please list any medication your child is taking or has taken in the last 6 months (if any):

Allergy Information Please provide as much information as possible so we can best meet the needs of your child.

If yes, please list the steps of your child's allergy action plan:

Does your child currently have an EpiPen?

If YES, please continue below, if NO cont. with section 4

If yes, please list the child's allergies being as specific as possible:

Does your child have allergies?

Parent & Emergency Contact Information

4100 Sherbrooke St. W., Westmount, Quebec, H3Z 1A5 - Tel: 514•937•7058 - www.templemontreal.ca

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4 - TELL US ABOUT YOUR CHILD How does your child prefer to learn? (Select all that apply)

List 3 things your child enjoys doing in her/ his spare time.

Tell us 3 strengths your child has.

Does your child have any strong aversions to specific activities?

What do you hope your child accomplishes this year at Torah School?

For more information about inclusion at Temple contact: rabbigreenspan@templemontreal.ca. Temple means Inclusion.

Would you like a phone call before the beginning of the school year to discuss your child's specific needs?

What other information can you provide that will help us welcome your child? (i.e. challenges, special needs, etc)

Reading and writing

Listening

Hands-on practice

Observation

Unsure

Other (Please be specific)

4100 Sherbrooke St. W., Westmount, Quebec, H3Z 1A5 - Tel: 514•937•7058 - www.templemontreal.ca

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I would like to be included in a Torah School directory for distribution among Torah School families ONLY, (including primary contact information for each child/family).

The Board of Trustees of Temple Emanu-El-Beth Sholom reaffirms the Congregation's policy and tradition that Torah School students commit themselves to their studies through Bar/Bat Mitzvah. A Temple membership and a commitment to the program are required before setting a bar/bat mitzvah date. Temple commits to providing a quality educational and social experience for all children and their families, including formal classroom learning and family educational experiences. All of the information above is correct to the best of my knowledge. By signing this form, I acknowledge my family's commitment to Torah School for the coming year. Emergency Medical Authorization In case of a medical EMERGENCY or sudden illness, and only in the event that I cannot be reached, I hereby authorize Temple Emanu-El-Beth Sholom to provide first aid to my child, and, if necessary, to ensure that emergency care is provided. If transportation because of emergency becomes necessary, I agree to pay any expenses incurred. I have given all pertinent information which may be needed in the event of such an emergency, and will inform the Temple of any changes in health of a serious nature.

Parent/Guardian Print Name Date

Parent/Guardian Signature

Temple often takes photos and videos during programs for possible use in future print, internet and Facebook marketing and publicity. We never publish any child's name. Please select one.

Signature is required. Typing your name for electronic submission serves as an electronic signature.

4100 Sherbrooke St. W., Westmount, Quebec, H3Z 1A5 - Tel: 514•937•7058 - www.templemontreal.ca

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5 - NEW FAMILIES ONLY Please fill out this section only if you're new to Temple and have never registered for Torah School previously.

Parent/Guardian #2's Religious Background

Parent/Guardian #1's Religious Background

Please specify where and for how long.

Does your child have any previous formal Hebrew Education?

Please specify where and for how long.

Does your child have any previous formal Jewish Education?

Temple Members

Non-Members

Early Bird

Until June 30th

After June 30th

Non-Members inc. security fee

Early Bird Until June 30th

Non-Members inc. security fee

Early Bird After June 30th

Junior Torah School $215 $225 $540 $550Grades 1 through 3 $240 $250 $590 $600Grades 4 and 5 $375 $390 $870 $900Grade 6* $1100 $1125 $1565 $1600Grade 7* $1125 $1300 Not available Not availableGrade 8 No Charge No Charge $180 $225Grade 9** No Charge No Charge $180 $225

6 -TUITION Although Torah School is open to non-members, we invite you to explore membership. Contact: RabbiGrushcow@templemontreal.ca

* Grade 6 tuition includes 9 half-hour Hebrew tutoring sessions; Grade 7 tuition includes 20 half-hour Hebrew tutoring sessions for B'nai Mitzvah preparation. ** Grade 9 concludes with the ceremony of Confirmation, held on Erev Shavuot, (May 30, 2017). A Confirmation fee of $100 for gowns and flowers will be billed separately. *** Our satellite program at École Buissonnière, in Outremount, is held on Tuesdays from 4 to 5:30 pm. It is open to all interested students from Pre-K to grade 4.

École Buissonnière *** Members and Non-Members

All grades

Early Bird until June 30th $500

After June 30th $525

The security fee is included in member contributions.

4100 Sherbrooke St. W., Westmount, Quebec, H3Z 1A5 - Tel: 514•937•7058 - www.templemontreal.ca

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I am paying my full tuition of

I am paying in 2 installments with cheques, one dated today and the other one January 10, 2017.

I have included a contribution of $

If you have any questions regarding your family’s educational and/or religious journey, please contact Rabbi Greenspan (rabbigreenspan@templemontreal.ca) or Rabbi Grushcow (rabbigrushcow@templemontreal.ca).

IF PAYING BY CREDIT CARD, YOU MAY PAY THE FULL AMOUNT WITH PAYPAL (CLICK ON THE LINK AT THE BOTTOM OF THE WEB PAGE), OR COMPLETE AND SIGN THE FORM BELOW AND THE OFFICE WILL CHARGE YOUR CARD ACCORDINGLY.

Charge my credit card: Amount paid by credit card

Expiry date

Name as on credit card

Credit Card # Signature

Total dues$ Amount paid Temple Member Date received A/R A/R initial Received TS TS Initial

Notes

OFFICE USE ONLY

Tuition does not cover the full cost of Torah School. In addition, we offer tuition abatements to those who need them. If you are able, please support Torah School with a donation.

CVV

I am paying in 2 installments by credit card, one payment today and the other one January 10, 2017.

I will pay by:

Cheques payable to Temple Emanu-El-Beth Sholom.