Please write first name of student

Student's grade in 2017-2018 school year:

If you choose to indicate a gender for your child, please check below.

What school will your child attend during the week?

Street Name and #, City, State, Zip Code

Student Home Phone #

Parent/Guardian # 1 First Name

Parent/Guardian # 1 email address

Street Name, #, City, State, Zip Code - if same as student just write "same."

Parent Guardian Home Phone # if different from Student's Home Phone #

Parent/Guardian # 1 work phone #

Parent/Guardian # 1 cell phone #

Parent/Guardian # 2 Last Name

Parent/Guardian # 2 First Name

Street Name, #, City, State, Zip Code - if same as student just write "same."

Parent/Guardian # 2 home phone # if different from Student's Home Phone #

Parent/Guardian # 2 work phone #

Parent/Guardian # 2 cell phone #

Parent/Guardian # 2 email

Please let us know if you are able to volunteer for any of the following. Give us your name and check any or all of the activities listed below:

Please inform us of any medical conditions that may impact your child during school hours. If you need more space to explain, you may  choose to email this information to education@tbe.org.  You may also contact Lisa Gittelman Udi directly at 203-322-6901 x305.

Name of Insurance Company, policy #:

Physician Name # Phone # in case of medical emergency:

Dentist Name # Phone # in case of dental emergency:

In case of an emergency and parent/guardian cannot be reached, please contact: the following - up to 2 names and phone #s:

 If your child has any type of special learning need,  please explain here:  Alternatively, you can choose to email this information to the Education Director at eddir@tbe.org or contact Lisa Gittelman Udi directly at 203-322-6901 x305.

If your child receives special services for secular school, (special education classes, resource room put-out, other)  please explain here.  Alternatively, you can choose to email this information to the Education Director at eddir@tbe.org or contact Lisa directly at 203-322-6901 x305.

I give permission for photos of my child to appear on the following: (check all that apply)

Is there anything else you would like us to know about your child? (Subjects he/she particularly likes or dislikes, speical interests, hobbies, areas of strength or challenges, significant changes in school or at home that your child has experienced in the past year, etc.)?

YOUR REGISTRATION WILL BE FULLY ACTIVE WHEN WE HAVE RECEIVED A TUITION PAYMENT OR CONFIRMATION THAT YOU HAVE CONTACTED STEVE LANDER TO MAKE ALTERNATIVE  PAYMENT ARRANGEMENTS. Please indicate how you will make the payment for your student's registration below.The full tuition fees are :                                                                                       K-2nd Grade - $980.00,                                                                                                                                                                             3rd-7th - $1265.                                                                                                                                                                                     Checks should be sent to Temple Beth El 350 Roxbury Rd. Stamford, CT 06902.  If you choose to pay by credit card, please contact Linda at 203-322-6901 x302.  There will be a 3% fee to cover our credit card fees. To pay online using your checking account, go to tinyurl.com/tbersfees2017.  If you choose "Alternative Payment Arrangement,"  please contact Steve Lander at 203-322-6901 x304. To register your child for K'tanin, K'tanim B'Ivrit, or Z'man L'Ivrit, please go to this link: TINYURL.COM/TBEHEVREPROGRAMSREG2017.