The Temple-Tifereth Israel Learning Center 2021-2022 Learner Information

We look forward to welcoming back your family for the 2021-2022 year at The Temple-Tifereth Israel Learning Center. Thank you for registering! It is bound to be an exciting year, as we welcome Dina Rock as our new Director of Learning, and welcome all of YOU back to learn, explore, pray and grow! Please complete the form below so we are ready to welcome back your family as best we can.

Required fields are denoted with an asterisk (*). If you are having trouble submitting this form please check all sections for missing required information. The missing information will be highlighted in red.

Parent/Guardian 1

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

* Parent/Guardian 1, Full Name

Parent/Guardian 1 Hebrew Name (Phonetically)

* Street Address Line 1

Street Address Line 2

* City, State and Zipcode

* Email Address

Home Phone Number

Work Phone Number

* Mobile Phone Number

Spouse's Full Name (if applicable)

Parent/Guardian 2

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

Parent/Guardian 2, Full Name

Parent/Guardian 2 Hebrew Name (Phonetically)

Street Address Line 1 (if different than above)

Street Address Line 2

City, State and Zipcode

Home Phone Number

Work Phone Number

Mobile Phone Number

Spouse's Full Name (if applicable)

Emergency Contact Information

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/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 Pronouns (she/her, he/him, they/them, other)

* Learner 1 School (including school district if applicable)

* Does your child have allergies or any medical issues? (If yes, please specify allergies/medical issues below and list medications and treatment protocol.)

Yes

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

* Does your child have any mental health needs that we should be aware of? (If yes, please share necessary information below so we can support your child's needs.)

Yes

Relevant mental health background information

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.

Learners may request two friends to be with during temple education. 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:

If you have only one learner, please skip to the end of this form to complete the payment and consent options.

Learner 2 Information

Learner 2 Full Name

Learner 2 Pronouns (she/her, he/him, they/them, other)

Learner 2 School (including school district if applicable)

Does your child have allergies or any medical issues? (If yes, please specify allergies/medical issues below and list medications and treatment protocol.)

Yes

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

Has your child have any mental health needs that we should be aware of? (If yes, please share necessary information below or email [email protected] so we can support your child's needs.)

Yes

Relevant mental health background information

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.

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

If you have two learners, please skip to the end of this form to complete the payment and consent options.

Learner 3 Information

Learner 3 Full Name

Learner 3 Pronouns (she/her, he/him, they/them, other)

Learner 3 School (including school district if applicable)

Does your child have allergies or any medical issues? (If yes, please specify allergies/medical issues below and list medications and treatment protocol.)

Yes

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

Has your child have any mental health needs that we should be aware of? (If yes, please share necessary information below or email [email protected] so we can support your child's needs.)

Yes

Relevant mental health background information

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.

If you have three learners, please skip to the end of this form to complete the payment and consent options.

Learner 4 Information

Learner 4 Full Name

Learner 4 Pronouns (she/her, he/him, they/them, other)

Does your child have allergies or any medical issues? (If yes, please specify allergies/medical issues below and list medications and treatment protocol.)

Yes

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

Has your child have any mental health needs that we should be aware of? (If yes, please share necessary information below or email [email protected] so we can support your child's needs.)

Yes

Relevant mental health background information

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.

Account Details

E-mail

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First Name

Last Name

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Account

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The Temple-Tifereth Israel Learning Center 2021-2022 Learner Information

Parent/Guardian 1

Parent/Guardian 2

Emergency Contact Information

Learner 1 Information

Learner 2 Information

Learner 3 Information

Learner 4 Information

Permissions, Consents, Donations, and Payments

Account Details

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