Registration for Hebrew High School - Form

Greenburgh Hebrew Center Religious School
515 Broadway
Dobbs Ferry, NY 10522
914-693-4260 (main office)
914-479-1400 (school)
www.ghcny.org
Marcia Lane, Principal Religious School
marcia.lane@ghcny.org

Registration Form For Hebrew High School
2022-2023

(Please note...if you are a member of GHC, please make sure you complete this form by first logging into your GHC account. Any issues, please contact the office at office@ghcny.org...Thank you!)

* Student's Last Name

Student's First Name

* Date of Birth

Please enter your child's Hebrew name

* Home Phone

* Grade in Sept

* Family Synagogue Affiliation

Please Select OneGHCNoneOther - Please be more specific

If you clicked other, please explain:

Use of Images in the Media

Please Select OneYes, I do hereby consent and agree with the statement below and allow the use of images of myself or my child in the media.No, I do not consent to the use of images of myself or my child in the media.

Greenburgh Hebrew Center Use of Images in the Media:

Greenburgh Hebrew Center, its employees, or agents have the right to take photographs, videotape, or digital recordings ("Images") of me or my child and to use these in any and all media exclusively for the purpose of communicating the educational activities of the synagogue. I do hereby release to Greenburgh Hebrew Center, its agents, and employees all rights to exhibit this work in print and electronic form publicly or privately. I waIve any rights, claims, or interest I may have to control the use of my image in whatever media used. Child last names will not be used with media images.

* Parent/Legal Guardian Name:

Please enter the name of the parent or legal guardian who completed the "Use of Images in the Media" form:

Consent for Emergency Medical Treatment
PART I OR II MUST BE COMPLETED BELOW:

PART I - Providing Consent for Emergency Medical Treatment

PART I: Yes, I give my consent for emergency medical treatment of my child as outlined below:

IF REASONABLE ATTEMPTS TO REACH ME FAIL, I HEREBY GIVE MY CONSENT FOR:
1. The administration of any treatment deemed necessary by the medical professionals I have listed as my child's physician in the "emergency contacts" section of this enrollment form.
2. If my designated medical professional is not available, by another medical professional; and
3. The transfer of my child to any hospital reasonably accessible.

Parent/Legal Guardian Name:

Please enter the name of the parent or legal guardian who completed Part I - Consent for Emergency Medical Treatment

PART II - Consent is NOT given for Emergency Medical Treatment

PART II: NO, I do NOT give my consent for emergency medical treatment of my child.

Parent/Legal Guardian Name:

Please enter the name of the parent or legal guardian who completed Part II - Consent is not given for emergency medical treatment.

Parent/Guardian Information:

* Parent/Guardian 1: First Name

* Parent/Guardian 1: Last Name

* Relationship of Parent/Guardian 1 to the child:

* Street Address of Parent/Guardian 1

City

* State

* Zip

* Email address for Parent/Guardian 1:

* Home phone Parent/Guardian 1:

Cell phone for Parent/Guardian 1:

* Which is the best phone number to contact Parent/Guardian 1?

Please Select OneHome phoneCell phone

Parent/Guardian 2: First Name

Parent/Guardian 2: Last Name

Relationship of Parent/Guardian 2 to the child:

Street Address of Parent/Guardian 2

If same as Parent/Guardian 1 just write "same"

City

State

Zip

Email address for Parent/Guardian 2:

Home phone for Parent/Guardian 2:

Cell phone for Parent/Guardian 2:

Which is the best phone number to contact Parent/Guardian 2?

Please Select OneHome phoneCell phone

Additional Information about the child:

* Does this child have an IEP, 504 Plan, or other academic plan in place in their secular school?

Please Select OneYesNo

If yes, please provide information on your child's academic plan:

* Is there anything we need to know or be sensitive to concerning the emotional or behavioral well-being of this child?

Please Select OneYesNo

If yes, please provide information on your child's emotional or behavioral well-being.

* Does this child have any food allergies?

Please Select OneYesNo

If yes, please provide specific information on your child's food allergies:

If your child has a food allergy, we require that an unopened EpiPen pack along with instructions and contact phone numbers be provided to the Director of Education in a plastic zip-lock bag.

* Does this child have any other health concerns that could affect them at Religious School?

Please Select OneYesNo

If yes, please provide specific information on your child's health concerns.

If there is a chance that your child will need medication, such as an inhaler for asthma, during school hours, please provide the Director of Education with an unopened package of the medication, instructions and contact phone numbers in a plastic zip-lock bag.

Please share any other information that will help us create a safe, effective, and meaningful educational experience for your child:

Previous Religious School Training, if any, if your child did not attend GHC's Religious School:

Emergency Contact Information for the first child:

Name of child's Primary Physician

Phone number of child's Primary Physician

Name of child's Dentist

Phone number of child's Dentist

* Emergency Contact 1

Please enter the name of an emergency contact who is not a Parent/Guardian of the child.

* Relationship to Emergency Contact 1

For example: Aunt, Uncle, Cousin, or friend

* Emergency Contact 1 Phone Number

Emergency Contact 2

Please enter the name of an emergency contact who is not a Parent/Guardian of the child.

Relationship to Emergency Contact 2

For example: Aunt, Uncle, Cousin, or friend

Emergency Contact 2 Phone Number

Please list all other children in your family:

Name

Date of Birth

Grade

Name

Date of Birth

Grade

Name

Date of Birth

Grade

Total number enrolled in GHC Religious School

Hebrew High School Tuition for this school year: $500.00

Tuition Payment

Please Select OneI will pay by credit card. Please go to the payment section on the home page of our website.I will pay by check and send it to the GHC office. Check made out to Greenburgh Hebrew CenterPlease charge my account

THANK YOU!! Your payment is greatly appreciated.
Any issues, please contact the office or the Director of Education

* Parent/Legal Guardian who completed this form

By clicking submit below, you agree to have your child follow all protocols and proceedures instituted by Greenburgh Hebrew Center. Thank you!

* Date Submitted