2021-2022 HSRS Registration - Form - Congregation Har Shalom

Har Shalom Religious School

2021-2022/5782

Enrollment Information

“If you truly wish your child to study Torah, study it yourself in their presence.”

- Rabbi Menachem Mendel

Please submit all HSRS 5782 Registration forms by August 20th.

You must complete ALL sections of the form, even for returning students - Registration Form, Emergency/Medical, Student Profile, and Parent Volunteer.

If you have any questions, please contact Ruth M. Szykman, Director of Education at 301-404-9155 or by email.

The HSRS 2021-2022 Academic Year will begin on Sunday. September 12th for all grades.

FAMILY INFORMATION

* Primary Adult First Name

* Primary Adult Last Name

* Relationship to Student(s)

* Primary Adult Email

* Primary Adult Cell Phone

Primary Adult Home Phone

* Primary Adult Address Line 1

Primary Adult Address Line 2

* Primary Adult Address City

* Primary Adult Address State

* Primary Adult Address Zip Code

Is there another adult in the household?

Yes, with the same address as the Primary AdultYes, with a different address as the Primary AdultNo

Secondary Adult Last Name

Secondary Adult First Name

Secondary Adult Relationship to Student

Secondary Adult Email Address

Secondary Adult Cell Number

Secondary Address Line 1

Secondary Address Line 2

Secondary Address City

Secondary Address State

Secondary Address Zip Code

STUDENT INFORMATION

* Student #1 First Name

* Last Name

Hebrew Name

* Date of Birth

MM/DD/YY

* Age

* Name of Secular School

* Grade in Fall 2021

* High School Graduation Year

* Please select the grade your child will be enrolling in for the 2021-2022 HSRS school year

* Did your child attend Religious School in 2020-2021?

Please Select OneYes, HSRSYes, at another school (please indicate below)No

Which Religious School did your child attend last year?

For Grades 3-7 Weekday Hebrew Classes:
Please rank your preference below (we will try our best to accommodate)

Tuesdays - 4:30pm - 5:00pm

Tuesdays - 5:15pm - 5:45pm

Wednesdays - 4:30pm - 5:00pm

Wednesdays - 5:15pm - 5:45pm

EMERGENCY/MEDICAL FORM
Every K-7th Grade student at HSRS must have this from on file in order to ensure their safety during school-sponsored programs:

* In the event that I cannot be reached in an emergency, I hereby give permission for my child, a student at HSRS, to be transported to a hospital or physician’s office for treatment. I hereby release Har Shalom and its employees from liability in the case of an accident involving my child while they are participating in any school sponsored activity.

Please Select OneYesNo

* Signature (please write in your name)

Date

* Emergency Contact #1

* Relationship to Student

* Phone Number

* Emergency Contact #2

* Relationship to Student

* Phone Number

Please list any food, drug or other allergies:

Please list any medications your child is currently taking and any health concerns:

STUDENT PROFILE
It would be helpful for the HSRS teaching staff to know more about your child. Please answer the following questions as completely as possible. Feel free to provide additional information or reports if you believe that would help us teach your child more effectively. If you answer “yes” to any of the following questions, please explain in detail. All information will be kept strictly confidential.

* I would like Ruth to contact me to discuss my student(s)

Please Select OneYesNo

Check here if this is your student’s first year at HSRS.

Does your child have any learning difficulties? Does your child receive any special education services at their school?

Does your child have any physical challenges?

Are there any situations at home that the school should know about?

What is your child’s reading level in English?

Above grade levelOn grade levelBelow grade level

Overall, how would you describe your child’s behavior in academic settings? (participates fully, reluctant, hesitant, etc)

How can the teacher make your child’s HSRS experience successful?

* Do you have another child to register?

Please Select OneNoYes

Student #2 First Name

Student #2 Last Name

Hebrew Name

Date of Birth

MM/DD/YY

Age

Name of Secular School

* Grade in Fall 2021

* High School Graduation Year

Please select the grade your child will be enrolling in for the HSRS 2021-2022 school year

Did your child attend Religious School in 2020-2021?

Please Select OneYes, HSRSYes, at another school (please indicate below)No

Which Religious School did your child attend last year?

For Grades 3-7 Weekday Hebrew Classes:
Please rank the options below (we will try our best to accommodate)

Tuesdays - 4:30pm - 5:00pm

Tuesdays - 5:15pm - 5:45pm

Wednesdays - 4:30pm - 5:00pm

Wednesdays - 5:15pm - 5:45pm

EMERGENCY/MEDICAL FORM
Every K-7th Grade student at HSRS must have this from on file in order to ensure their safety during school-sponsored programs:

In the event that I cannot be reached in an emergency, I hereby give permission for my child, a student at HSRS, to be transported to a hospital or physician’s office for treatment. I hereby release Har Shalom and its employees from liability in the case of an accident involving my child while they are participating in any school sponsored activity.

YesNo

Signature (please write in your name)

Date

Emergency Contact #1

Relationship to Student

Phone Number

Emergency Contact #2

Relationship to Student

Phone Number

Please list any food, drug or other allergies:

Please list any medications your child is currently taking and any health concerns:

I would like Ruth to contact me to discuss my student(s)

Please Select One:YesNo

Check here if this is your student’s first year at HSRS.

Does your child have any learning difficulties? Does your child receive any special education services at their school?

Does your child have any physical challenges?

Are there any situations at home that the school should know about?

What is your child’s reading level in English?

Above grade levelOn grade levelBelow grade level

Overall, how would you describe your child’s behavior in academic settings? (participates fully, reluctant, hesitant, etc)

How can the teacher make your child’s HSRS experience successful?

* Photo Authorization: I hereby give permission to HSRS to use photos of my child(ren) taken at Har Shalom and/or during HSRS events on social media, promotional publicity and ads.

Please Select OneYesNo

* Signature (please write in your name)

Date

ADULT VOLUNTEER FORM

We invite all families to join our committee and help shape our school and youth program. Do a little or do a lot, you can really make a difference. We'll add you to the email list and hope to see you soon.

I'd like to join!

Primary Adult Name

Primary Adult Occupation

I'd like to join!

Secondary Adult Name

Secondary Adult Occupation

HSRS Proposed Tuition and Fees 2021-2022

		Days	Tuition	Registration	Total
Members	Grades K - 2nd	Sunday	$1,150.00	$175.00	$1,325.00
	Grades 3rd - 7th	Sunday Tuesday or Wednesday	$1,730.00	$175.00	$1,905.00

Non Members	Grades K-1st	Sunday	$1,903.00	$175.00	$2,078.00
	Grade 2nd	Sunday	$2,190.00	$175.00	$2,365.00

Tuition is billed over 10 months. Registration fee is due now.
*Early Bird Special*Register before June 30th and we'll waive the Registration fee!
**Ira & MaryJo Sherman ECC Families enjoy a 50% discount on Kindergarten!

Registration Fee Due Now

$175 Registration Fee Per Child Due Now

EARLY BIRD SPECIAL - No Registration Fee prior to June 30thRegistration for 1 child ($175)Registration for 2 children ($350)