2022-23 Youth Education Registration

Temple Micah Youth Education Student Registration Form
with Emergency Contact Information and Participation Waivers

2022-2023/ 5783

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

Family Information

Parent/Legal Guardian Name 1

Phone

Email Address

My pronouns are:

Will you be participating in Mishpacha! this year?

YesNo

Parent/Legal Guardian Name 2

Phone (1)

Email Address

My pronouns are:

Will you be participating in Mishpacha! this year?

YesNo

Home Address for Parent/Guardian 1 listed above

Home Address for Parent/Guardian 2 (if different from Parent/Guardian 1 above)

Additional Necessary Parent/Guardian Information

Are you a member of Temple Micah?

Emergency Procedural 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:

School Grade Fall 2022:

Pronouns

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:

School Grade Fall 2022:

Pronouns

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:

School Grade Fall 2022:

Pronouns

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 DIRECTLY IF YOU HAVE MORE THAN 3 CHILDREN TO ENROLL!
amy.krivel@micahdenver.org

TEMPLE MICAH YOUTH EDUCATION

TUITION PAYMENT CONTRACT

Brit/Contract between Temple Micah and All Families participating in Youth Education

TUITION RATES:

Member = in good standing of Temple Micah

Non-member = unaffiliated for first year of participation

Micah Minis (Grades Pre-K-1)	$270/student member $400/student non-member
Micah Minions (Grades 2-3)	$450/student member $740/student non-member
Micah Mensches (Grades 4-5)	$860/student member $1220/student non-member
B’nai Mitzvahs in 6th Grade	$960/student member $1220/student non-member
B’nai Mitzvahs in 7th Grade	$1220/student member
Mishpacha!	$1600/family if members $2600/family if non-members
Madrichim	$125/teen member $265/teen member
Chai School Social	$95/teen member $220/teen non-member
Chai School Justice	$360/teen member $580/teen non-member

(Please choose one)

* CALCULATE TOTAL TUITION and ENTER HERE:

Total Payment Included Today

This is a brit/contract with Temple Micah and I commit to full payment of 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).

Please list the name(s) of the student(s) and the program(s) in which they will be participating this year.

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:

Where would you like us to send confirmation?

Include your email address here: amy.krivel@micahdenver.org.

Tue, April 23 2024 15 Nisan 5784