Online LAMED Registration

Parent/Guardian Information

Parent/Guardian #1 Name*

Prefix First Last

Email*

Home Phone*

Cell Phone*

Work Phone*

Home Address*

Street Address Address Line 2 City State ZIP Code

Is there a second Parent/Guardian?*

Yes

No

Parent/Guardian #2 Name

Prefix First Last

Does Parent/Guardian #2 want his/her contact information listed in the school directory?

Yes

No

Home Phone (if different from Parent/Guardian #1)

Cell Phone

Work Phone

Home Address (if different from Parent/Guardian #1)

Street Address Address Line 2 City State ZIP Code

Additional Emails

The LAMED at Gratz program uses email as the primary way to inform you about important dates, special programs, and other key information throughout the school year. If you wish to have anyone else receive informational school emails, please enter their email address(es), below:

Student Information

Student's Name*

First Middle Last

Hebrew Name (if known)

Date of Birth*

School district in which the student resides?*

School

Enroll in which grade level for 2018-2019?*

Which synangogue does the student attend?*

Student's Phone

Student's Email*

Does your teen have any special learning needs?*

This information will be kept strictly confidential and will help us to effectively educate your child.

Yes

No

The Director of Education will contact you to discuss your child's special needs.

Medical Information

Does your teen have any allergies?*

Yes

No

Please describe the allergies:

Does your teen have any special medical conditions?*

Yes

No

Please describe the medical conditions:

Does your teen regularly take any medication(s)?*

Yes

No

Please describe the medication(s):

Emergency Contact Information

Emergency Contact*

In the unlikely case of an emergency concerning your teen, we would first attempt to contact a parent. If we cannot reach a parent, we should call the following emergency contact:

First Last

Relationship to student:*

Phone*

Alternate Phone

Enrollment

From time to time photographs of the students are taken during school events and activities which Congregation Kol Ami / Old York Road Temple Beth Am may want to utilize in its print publications, online publications, presentations, website, and social media pages.

By checking the box, I am giving Congregation Kol Ami / Old York Road Temple Beth Am my permission to use my child’s photograph.

A bill for the program will be mailed to you. Please feel free to contact us if you need to make any special payment arrangements. Inquire with your home congregation about scholarship opportunities. By checking the following box, I attest that I am a legal parent of the student entered in this form, and that all of the information I have entered is true and correct. I also agree to pay the program tuition and fee.*

Enroll my teen in the LAMED at Gratz program