2021-22 RELIGIOUS SCHOOL REGISTRATION

Temple Micah Religious School Student Registration Form
with Emergency Contact Information and Participation Waivers

2021-2022/ 5782

Director of Youth Education: Amy Krivel, amy.krivel@micahdenver.org
Senior Rabbi: Rabbi Adam Morris

Family Information

Parent/Legal Guardian Name 1

Phone (1)

Phone (2)

Email Address

Parent/Legal Guardian Name 2

Phone (1)

Phone (2)

Email Address

Home Address(es)

Additional Necessary Parent/Guardian Information

Are you a member of Temple Micah?

Emergency Contact Information

In case of MILD injury, may we administer first aid to your child?

In case of SERIOUS illness or injury when parents cannot be contacted, may we call 911 if necessary?

If the answer to the above question is "no", please indicate what you'd like done in case of life-threatening emergencies.

Please list two local emergency contacts in the event that parent/guardian cannot be reached.

Name:

Relationship:

Phone:

Name:

Relationship:

Phone:

In case of a medical emergency, I authorize the staff of TMRS to obtain emergency medical treatment for my child as detailed above.

Please type your name as parent or guardian here to indicate your signature and consent:

Date:

Student Information

1. Name of Student (English)

and (Hebrew)

Date of Birth:

Gender:

School Grade Fall 2021:

Known food or drug allergies or specific diet:

Daily medications, if any:

Learning difficulties that we should know about, if any:

Anything else we should know about this student?

2. Name of Student (English)

and (Hebrew)

Date of Birth:

Gender:

School Grade Fall 2021:

Known food or drug allergies or specific diet:

Daily medications, if any:

Learning difficulties that we should know about, if any:

Anything else we should know about this student?

3. Name of Student (English)

and (Hebrew)

Date of Birth:

Gender:

School Grade Fall 2021:

Known food or drug allergies or specific diet:

Daily medications, if any:

Learning difficulties that we should know about, if any:

Anything else we should know about this student?

PLEASE CONTACT TEMPLE MICAH IF YOU HAVE MORE THAN 3 CHILDREN TO ENROLL!

TEMPLE MICAH RELIGIOUS SCHOOL

TUITION PAYMENT CONTRACT

Brit/Contract between Temple Micah and Religious School Families

TUITION RATES:

Member = in good standing of Temple Micah

Non-member = unaffiliated for first year of participation

Micah Minis (Grades Pre-K-1)	$250/student member $400/student non-member
Micah Minions (Grades 2-3)	$430/student member $700/student non-member
Micah Mensches (Grades 4-5)	$650/student member $895/student non-member
B’nai Mitzvahs (Grades 6-7)	$740/student member $995/student non-member
Madrichim Mentoring (Grades 8-9)	$180 per teen member (8th only) $440 non-member
Mission Chai School	$340 per teen member $630 per teen non-member

(Please choose one)

a. Student's name

Total Tuition Due

b. Student's name

Total Tuition Due

c. Student's name

Total Tuition Due

* CALCULATE TOTAL TUITION and ENTER HERE:

This is a brit/contract with Temple Micah and I commit to full payment of religious school tuition. I realize that if I am not able to complete this payment on time, I must seek assistance from the temple staff, otherwise my child(ren) may not be able to return until such payment is resolved.

Please type your name here to indicate your signature and consent:

Date:

RELEASE OF PHOTOGRAPHS FOR MINORS

I, parent or guardian, hereby grant permission to Temple Micah to take and use: photographs and/or digital images of my child for use in news releases, promotional materials, Micah Facebook Page, internal emails, and other electronic communications. I further agree that my child's name and identity may be revealed in descriptive text or commentary in connection with the image(s).

List child's name(s)

Please choose one:

Please type your name here to indicate parent or guardian signature:

Thank you for registering for Temple Micah Religious School! Please continue to the next page to make your payment. Contact Temple Micah if you have any questions or need assistance.

Date:

Wed, October 27 2021 21 Cheshvan 5782