Mekor Shalom Jewish Learning Program Registration 2024-25

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Welcome to Mekor Shalom Jewish Learning Program Registration
for the 2024-25 school year!

Mekor Shalom is proud of the Jewish Learning Program. Each participant experiences Jewish learning in a safe, nurturing, meaningful, and engaging environment.

Jewish Learning Program Schedule:
Sundays:  Grades K-7 meet at Mekor Shalom, 9:30 a.m. to 12:00 p.m.
Wednesdays: Grades 3-7 meet via Zoom, 5:00-6:30 p.m.

Please fill out this form, even if you have filled out a registration
form in prior years.

Student #1

First Name

Last Name

Preferred Name:

Pronouns:

Please indicate (e.g. She/Her/Hers, He/Him/His, They/Them/Theirs, a combination):

Grade in school

Please list any food allergies, medical concerns, and medications:

Please share any circumstances or concerns related to your child’s learning style and/or request a meeting) to discuss:

Once you have entered this information for each student enrolling, please continue on to the next section.

Student #2

First Name

Last Name

Preferred Name:

Pronouns:

Please indicate (e.g. She/Her/Hers, He/Him/His, They/Them/Theirs, a combination):

Grade in school

Please list any food allergies, medical concerns, and medications:

Please share any circumstances or concerns related to your child’s learning style (and/or request a meeting) to discuss:

Student #3

First Name

Last Name

Preferred Name:

Pronouns:

Please indicate (e.g. She/Her/Hers, He/Him/His, They/Them/Theirs, a combination):

Grade in school

Please list any food allergies, medical concerns, and medications:

Please share any circumstances or concerns related to your child’s learning style and/or request a meeting) to discuss:

Student #4

First Name

Last Name

Preferred Name:

Pronouns:

Please indicate (e.g. She/Her/Hers, He/Him/His, They/Them/Theirs, a combination):

Grade in school

Please list any food allergies, medical concerns, and medications:

Please share any circumstances or concerns related to your child’s learning style and/or request a meeting) to discuss:

Adult #1:

First Name

Last Name

Email Address:

Best contact phone number:

Adult #2:

First Name

Last Name

Email Address:

Best contact phone number:

Adult #3:

First Name

Last Name

Email Address:

Best contact phone number:

Adult #4:

First Name

Last Name

Email Address:

Best contact phone number:

Name:

Relationship to Student(s):

Best Contact Phone Number:

Please check if contact may pick up student(s) from school:

Name:

Relationship to Student(s):

Best Contact Phone Number:

Please check if contact may pick up student(s) from school:

Name of Physician:

Physician's Phone Number:

Jewish Learning Program Costs:
K-2nd grade students, $500.
3rd-7th grade students, $750.

There is a $50 discount if you elect to pay for the program costs in full when sessions begin. There is also a $50 discount for the second and successive participants(s) enrolled (the first participant is still full price).

Includes any books/supplies and a snacks for in-person meetings.

If you are paying for program costs today (either whole or in part),
please enter the amount below. If not, please leave it blank. Thank you.

Religious School Tuition to Be Paid Today (if applicable):

Photographs:

Please Select OneI agree.I do not agree.I give permission to Congregation Mekor Shalom to photograph my child(ren) and use image(s) for publication purposes whether electronic, print, digital, or electronic publishing via the Internet. Child(ren) will not be tagged in any images shared on official Mekor Shalom social media accounts.

Medical Release:

I hereby give permission for my/our child(ren):

* Please list child(ren)'s name(s):

to participate in the programs at Mekor Shalom including off campus trips. In the event of an emergency, surgical or otherwise, and I cannot be reached, I hereby give permission for my child to be transported to the nearest medical facility and specifically authorize the representative of Congregation Mekor Shalom to select a physician and/or authorize medical treatment, including hospitalization, anesthesia, injection, surgery or other measures which he/she feels are in the best interest of my child.

Congregation Mekor Shalom is hereby released and held harmless from any claim, judgment, awards, settlements, or damages to any person or property arising directly or indirectly out of my child’s participation in the programs at Mekor Shalom, including off campus trips or the Congregation’s selection of physician, hospital, or any other medical service for my child in a medical emergency, or in connection with therein during of any such medical treatment.

* I agree.

I agree.By checking the “I Agree” checkbox, I agree and it is my intent to electronically sign and electronically submit this Authorization. I understand that by checking the “I agree” checkbox, I will be applying my electronic signature to this Authorization and that I will be bound with the same force and effect as if I had signed this Authorization on paper by hand.

* Please enter your name:

So glad to have your child(ren) participating in the JLP (Jewish Learning Program) at Mekor Shalom!

It is a privilege for Mekor Shalom to provide a safe, nurturing, and engaging learning
environment for each participant who is enrolled in the program.

Thank you for the opportunity to teach your child(ren)!

Wed, October 16 2024 14 Tishrei 5785