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The Temple-Tifereth Israel Learning Center Registration and Payment Form 2020-2021

Please complete this form on a computer (not a cell phone or tablet). Some sections have required fields denoted with an asterisk (*). Please update all fields that may differ from last year to keep information current. If you are having trouble submitting this form please check all sections for missing required information which will be highlighted in light red.

Parent/Guardian 1 Information (Note: contains required fields)

All required fields have an asterisk (*). All fields must be filled in to be able to submit this form.

* Parent/Guardian 1, Full Name

* Street Address Line 1

Street Address Line 2

* City, State and Zipcode

* Email Address

Please enter at least one phone number below and type "n/a" in any that do not apply.

* Home Phone Number

* Work Phone Number

* Mobile Phone Number

* Do(es) learner(s) reside with both parents/guardian? (Check all that apply.)

Yes
No
Learner(s) reside with Parent/Guardian 1
Learner(s) reside with Parent/Guardian 2

* Marital Status (and if married please include spouse's full name)

* Please send all mailings and emails to the following: (Check all that apply.)

Parent/Guardian 1
Parent/Guardian 2

Parent/Guardian 2 (Note: contains required fields. If not applicable please type n/a in all fields)

All required fields have an asterisk (*). All fields must be filled in to be able to submit this form.

* Parent/Guardian 2

* Street Address Line 1

Street Address Line 2

* City, State and Zipcode

* Email

Please enter at least one phone number below and type "n/a" in any that do not apply.

* Home Phone Number

* Work Phone Number

* Mobile Phone Number

* Marital Status (and if married please include spouse's full name)

Emergency Contact Information (Note: contains required fields)

All required fields have an asterisk (*). All fields must be filled in to be able to submit this form.

Our policy is to call parents or guardians listed above first. We kindly request that you provide two emergency contacts in case you are not available.

* Emergency Contact 1 Full Name

* Best Phone Number

* Alternate Phone Number

* Relationship to Learner(s)

* Emergency Contact 2 Full Name

* Best Phone Number

* Alternate Phone Number

* Relationship to Learner(s)

Learner 1 Information

* Learner 1 Full Name

* Learner 1 Email (Type n/a if not applicable.)

* Learner 1 Cell Phone Number (Type n/a if not applicable.)

Learner 1 Hebrew Name (phonetically)

* Learner 1 Gender

* Learner 1 Birthdate (dd/mm/yyyy)

* Learner 1 School District or Private School

* Does your child have allergies or any medical issues? (If yes, please specify allergies/medical issues below and list medications and treatment protocol. If no,type n/a.)

	Yes
	No

* Learner 1 Allergies/Medical Issues

* Does your child have an IEP or 504 Plan? (If yes, please email your summary page to [email protected])

	Yes
	No

* Has your child ever received professional counseling? (If yes, please share necessary information below so we can support your child's needs. If no, type n/a.)

	Yes
	No

* Learner 1 Professional Counseling

* Please list any challenges associated with your child's learning.

* My child makes friends...

	Easily
	Fairly well
	With difficulty

* How would you describe your child to someone who has never met them?

If Learner 1 went to a Summer Camp, please type the camp name(s) here:

We ask about Summer Camps to help us plan for the "One Happy Camper" scholarship program (managed by the Jewish Education Center of Cle), as well as other possible scholarship funding here at Temple.

* Learner 1 Session Choice (Please select from the drop down options.)

Zoom sessions, 40-75 minutes in length (depending on age), will be scheduled during these time frames.

* Learner 1 Hebrew Choice (Please select from the drop down options. If your child is not in 3rd - 7th Grade select n/a.)

Zoom sessions, will be scheduled during these time frames.

* Learner 1 Grade Level and Fees. (Please select from the drop down options.)

Please note that you will be billed a $525 B'nai Mitzvah fee separately one year prior to your child's B'nai Mitzvah date.

Learners may request two friends to be with at temple. We do our best to place them with at least one mutual request. Please type in the name(s) of the friend(s) Learner 1 would like to be with at temple:

Learner 2 Information

Learner 2 Full Name (If you do not have a 2nd Learner then please skip to the end and fill out the payment choices below)

Learner 2 Email (Type n/a if not applicable.)

Learner 2 Cell Phone Number (Type n/a if not applicable.)

Learner 2 Hebrew Name (phonetically)

Learner 2 Gender

Learner 2 Birthdate (dd/mm/yyyy)

Learner 2 School District or Private School

Does your child have allergies or any medical issues? (If yes, please specify allergies/medical issues below and list medications and treatment protocol. If no,type n/a.)

	Yes
	No

Learner 2 Allergies/Medical Issues

Does your child have an IEP or 504 Plan? (If yes, please email your summary page to [email protected].)

	Yes
	No

Has your child ever received professional counseling? (If yes, please share necessalry information below so we can support your child's needs. If no, type n/a.)

	Yes
	No

Learner 2 Professional Counseling

Please list any challenges associated with your child's learning.

My child makes friends...

	Easily
	Fairly well
	With difficulty

How would you describe your child to someone who has never met them?

If Learner 2 went to a Summer Camp, please fill in the name(s) here:

We ask about Summer Camps to help us plan for the "One Happy Camper" scholarship program (managed by the Jewish Education Center of Cle), as well as other possible scholarship funding here at Temple.

Learner 2 Session Choice (Please select from the drop down options.)

Zoom sessions, 40-75 minutes in length (depending on age), will be scheduled during these time frames.

Learner 2 Hebrew Choice (Please select from the drop down options.If your child is not in 3rd - 7th Grade select n/a.)

Zoom sessions, will be scheduled during these time frames.

Learner 2 Grade Level and Fees. (Please select from the drop down options.)

Please note that you will be billed a $525 B'nai Mitzvah fee separately one year prior to your child's B'nai Mitzvah date.

Learners may request two friends to be with at temple. We do our best to place them with at least one mutual request. Please type in the name(s) of the friend(s) Learner 2 would like to be with at temple:

Learner 3 Information

Learner 3 Full Name (If you do not have a 3rd Learner then please skip down to the payment choices below)

Learner 3 Email (Type n/a if not applicable.)

Learner 3 Cell Phone Number (Type n/a if not applicable.)

Learner 3 Hebrew Name (phonetically)

Learner 3 Gender

Learner 3 Birthdate (dd/mm/yyyy)

Learner 3 School District or Private School

Does your child have allergies or any medical issues? (If yes, please specify allergies/medical issues below and list medications and treatment protocol. If no,type n/a.)

	Yes
	No

Learner 3 Allergies/Medical Issues

Does your child have an IEP or 504 Plan? (If yes, please email your summary page to [email protected])

	Yes
	No

Has your child ever received professional counseling? (If yes, please share necessary information below so we can support your child's needs. If no, type n/a.)

	Yes
	No

Student 3 Professional Counseling

Please list any challenges associated with your child's learning.

My child makes friends...

	Easily
	Fairly well
	With diffuculty

How would you describe your child to someone who has never met them?

If Learner 3 went to a Summer Camp, please fill in the name(s) here:

We ask about Summer Camps to help us plan for the "One Happy Camper" scholarship program (managed by the Jewish Education Center of Cle), as well as other possible scholarship funding here at Temple.

Learner 3 Session Choice (Please select from the drop down options.)

Zoom sessions, 40-75 minutes in length (depending on age), will be scheduled during these time frames.

Learner 3 Hebrew Choice (Please select from the drop down options. If your child is not in 3rd - 7th Grade select n/a.)

Zoom sessions, will be scheduled during these time frames.

Learner 3 Grade Level and Fees. (Please select from the drop down options.)

Please note that you will be billed a $525 B'nai Mitzvah fee separately one year prior to your child's B'nai Mitzvah date.

Learners may request two friends to be with at temple. We do our best to place them with at least one mutual request. Please type in the name(s) of the friend(s) Learner 3 would like to be with at temple:

Learner 4 Information

Learner 4 Full Name (If you do not have a 4th Learner then please skip down to the payment choices below)

Learner 4 Email (Type n/a if not applicable.)

Learner 4 Cell Phone Number (Type n/a if not applicable.)

Learner 4 Hebrew Name (phonetically)

Learner 4 Gender

Learner 4 Birthdate (dd/mm/yyyy)

Learner 4 School District or Private School

Does your child have allergies or any medical issues? (If yes, please specify allergies/medical issues below and list medications and treatment protocol. If no,type n/a.)

	Yes
	No

Learner 4 Allergies/Medical Issues

Does your child have an IEP or 504 Plan? (If yes, please email your summary page to [email protected])

	Yes
	No

Has your child ever received professional counseling? (If yes, please share necessary information below so we can support your child's needs. If no, type n/a.)

	Yes
	No

Learner 4 Prefessional Counseling

Please list any challenges associated with your child's learning.

My child makes friends...

	Easily
	Fairly well
	With difficutly

How would you describe your child to someone who has never met them?

If Learner 4 went to a Summer Camp, please fill in the name(s) here:

We ask about Summer Camps to help us plan for the "One Happy Camper" scholarship program (managed by the Jewish Education Center of Cle), as well as other possible scholarship funding here at Temple.

Learner 4 Session Choice (Please select from the drop down options.)

Zoom sessions, 40-75 minutes in length (depending on age), will be scheduled during these time frames.

Learner 4 Hebrew Choice (Please select form the drop down options. If your child is not in 3rd - 7th Grade select n/a.)

Zoom sessions, will be scheduled during these time frames.

Fees for Learner 4 Grade Level and Fees.(Please select from the drop down options.)

Please note that you will be billed a $525 B'nai Mitzvah fee separately one year prior to your child's B'nai Mitzvah date.

Learners may request two friends to be with at temple. We do our best to place them with at least one mutual request. Please type in the name(s) of the friend(s) Learner 4 would like to be with at temple:

Permissions, Consents, Donations, and Payments (Note: contains required fields)

All required fields have an asterisk (*). All fields must be filled in to be able to submit this form.

* I give The Temple-Tifereth Israel permission to escort my children within walking distance of their learning activities. (If we return to in person learning.)

* I give permission for my child's likeness, photo, or video to be used in The Temple-Tifereth Israel's communications, website and other media.

* I give permission for my child's likeness, photo, or video to be used for educational purposes on the Jewish Education Center of Cleveland's website and other media.

* I give permission for our contact information to be included and distributed on a grade level roster to encourage temple friendships.

Yes
Yes, but limited
No

* If you answered "Yes, but limited" above please type contact information that may be included and distributed on a grade level roster. (Type n/a if you clicked Yes or No above)

* EMERGENCY CONSENT: In the event reasonable attempts to contact me have been unsuccessful, I hereby give my consent for the administration of any treatment deemed necessary by a licensed physician or dentist and the transfer of my child to any hospital reasonably accessible. This authorization does not cover major surgery unless the medical opinions of two other licensed physicians or dentists, concurring in the necessity for such surgery, are obtained prior to the performance of such surgery.

* REFUSAL TO GRANT CONSENT: I DO NOT give my consent for emergency medical treatment of my child. In the event of illness or injury requiring emergency treatment, I wish The Learning Center to take the following action. (Type "n/a" if you DID give consent.)

* SUNDAY MORNING PICKUP PREFERENCE: The following people are authorized to pick up my child/ren if we return to in person learning. (Type n/a if this does not apply to your child/(ren).*

* SUNDAY MORNING PICKUP PREFERENCE (If we return to in person learning.)

Inside the building (Chapel for Pre-K to 3rd and room for 4th to 7th)
Carpool
n/a

I would like to add the following amount as a donation to the S. Darwin Noll Fund for Jewish Education to help other families afford Learning Center tuition at The Temple-Tifereth Israel: $

* Is your family enrolled in Shabbaton? (There is a Shabbaton Fee per family.)

	No	$0.00
	Yes	$36.00

Do you prefer to pay separate from this form? (Contact Hope [email protected] or 216-455-6052 by September 1st. Select "Yes" to pay with check, credit card, or create a payment plan with the Finance office. Select "No" to pay now through this form. 1,2, 3 or 4 monthly payment options are available.)

To pay online now – select “yes” and required fields will appear.

Account Details

Enter your name and e-mail address for your confirmation:

*E-mail

*First Name

*Last Name

Payment Information

Account

Credit Card

Name on Card

Card Type

Card Number

Expiration Date

Card Verification Number

Address Line 1

City

State/Province

Zip

Comments

Increase the payment amount by 3% to cover credit card fees (No fee for Checking)

Total:

The Temple-Tifereth Israel Learning Center Registration and Payment Form 2020-2021

Parent/Guardian 1 Information (Note: contains required fields)

Parent/Guardian 2 (Note: contains required fields. If not applicable please type n/a in all fields)