2022-23 CLAL Registration - Congregation Ner Tamid

Student 1

Student First Name

Student Last Name

Hebrew Name

Birthdate

Grade in CLAL

Secular School

Madrichim (gr. 8-10, must be enrolled in CLAL High)

Yes

Madrichim (gr. 11-12)

Yes

Does this student have an IEP (Individualized Education Program)?

YesNo

Allergies/Other health issues:

Student 2 (if no additional student proceed to Family Information)

Student First Name

Student Last Name

Hebrew Name

Birthdate

Grade in CLAL

Secular School

Madrichim (gr. 8-10, must be enrolled in CLAL High)

Yes

Madrichim (gr. 11-12)

Yes

Does this student have an IEP (Individualized Education Program)?

YesNo

Allergies/Other health issues:

Student 3 (if no additional student proceed to Family Information)

Student First Name

Student Last Name

Hebrew Name

Birthdate

Grade in CLAL

Secular School

Madrichim (gr. 8-10, must be enrolled in CLAL High)

Yes

Madrichim (gr. 11-12)

Yes

Does this student have an IEP (Individualized Education Program)?

YesNo

Allergies/Other health issues:

Student 4 (if no additional student proceed to Family Information)

Student First Name

Student Last Name

Hebrew Name

Birthdate

Grade in CLAL

Secular School

Madrichim (gr. 8-10, must be enrolled in CLAL High)

Yes

Madrichim (gr. 11-12)

Yes

Does this student have an IEP (Individualized Education Program)?

YesNo

Allergies/Other health issues:

Family Information

Is your family new to CLAL?

Yes

Parent 1-First Name

Parent 1-Last Name

Religious Background

Address

City

Zip Code

Home phone

Cell phone

Parent 2-First Name

Parent 2-Last Name

Religious Background

Address

City

Zip Code

Home Phone

Cell phone

Which email should we use for school notices?

If your family is new to this school, what is the Jewish educational background of your child/children?

Does child/children reside with both parents?

YesNo

If not, with whom does student(s) reside?

If not, should both parents receive school materials?

YesNo

If not, which parent should receive school materials?

Photo Release

Do you authorize Congregation Ner Tamid to use photos of your child/children in print?

YesNo

Do you authorize Congregation Ner Tamid to use photos of your child/children in online media?

YesNo

Field Trip Permission

Do you grant permission for your child/children to participate in all activities and go on all trips arranged by CNT/CLAL/CLAL High Staff?

YesNo, I understand that my refusal to consent will disallow my student(s) from going to the park or on class trips.

Medical Information

Doctor's Name

Doctor's Phone Number

Can your child/children be administered Tylenol by the staff?

YesNo

Can your child/children be administered Benadryl by the staff?

YesNo

Is there anything else that you feel is important for us to know about your child/children?

Emergency Contact Information (If the school is unable to reach either parent, you are authorized to release my child/children to the following people:)

Emergency Contact 1-Name

Emergency Contact 1-Phone

Emergency Contact 1-Relationship

Emergency Contact 2-Name

Emergency Contact 2-Phone

Emergency Contact 2-Relationship

Medical and Release Form: 2022-2023

I hereby authorize the Congregation Ner Tamid CLAL or its authorized representatives, as agent(s) for the undersigned to consent to any medical diagnosis or treatment rendered under the general or special supervision of any physician and/or surgeon licensed under the provisions of the California Medicine Practice Act, as is necessary for the benefit of my child/children. The authorization is given in advance of any specific diagnosis or treatment, and is given to provide authority and power on the part of the aforementioned agent(s) to give specific consent to any such diagnosis and/or treatment which the aforementioned physician and/or surgeon in the exercise of his/her judgment may deem advisable. This authorization is given pursuant to the provisions of Section 25.8 of the Civil Code of California. This authorization shall remain effective until the end of the current school year.

YesNo

Parent Signature

type name

Date