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2021-2022 -Kindergarten Connection Program

You should receive a confirmation email shortly after completion.

Family Information

Parent #1 Contact Information

* Parent #1 Name

* Home Phone

* Parent #1 Cell Phone

Parent #2 Contact Information

Parent #2 Name

Home Phone

(If Different)

Parent #2 Cell Phone

Family Address

* Street Address

* City, State, Zip

* Email address to receive school correspondence

Additional email(s) to receive school correspondence

* Child(ren)'s Physician Name and Phone Number

* Child(ren)'s Dentist/Orthodontist Name and Phone Number

Please provide us with an EMERGENCY CONTACT to be notified if both parents are unreachable.

* Name, Relationship & phone number

* I empower Temple Shaaray Tefila and its agents to act for me in accordance with their best judgement in case of an emergency. It is my understanding that all accidental health care and medical attention while my child is at school will be billed to me.

	yes, I authorize
	no, I do not authorize

* I furthermore give permission for photographs, slides, videos, or audiotapes of my child(ren) to be used for our website, public relations purposes, and promotion of Temple Shaaray Tefila and our school.

yes, I authorize
no, I do not authorize

Child 1

* Child 1 Name

* Please provide the name of private or public school for 2021 - 2022 school year

It is our goal to provide a warm, creative, and nurturing learning environment for each of our students. In order to provide the best education, we need to know as much as possible about your child. The more information you share, the better able we are to meet the needs of your student. Information will be shared with your child's classroom teacher unless you indicate otherwise.

Does this student have any special learning needs of behavioral issues/concerns? If so, please describe and note any successful strategies utilized in other school settings.

Please list any food/medication allergies

Please list any medications your child is currently taking

Child 2

Child 2 Name

Please provide the name of the public or private school for the 2021-2022 school year

Does this student have any special learning needs of behavioral issues/concerns? If so, please describe and note any successful strategies utilized in other school settings.

Please list any food/medication allergies

Please list any medications your child is currently taking

Account Details

Enter your name and e-mail address for your confirmation:

*E-mail

*First Name

*Last Name

Payment Information

Account

Credit Card

Name on Card

Card Type

Card Number

Expiration Date

Card Verification Number

Address Line 1

City

State/Province

Zip

Comments

Increase the amount by 3% to cover credit card fees. Please select YES to increase your payment.

Total: