2020-2021 HSRS Registration - Form - Congregation Har Shalom (Potomac)

Har Shalom Religious School

2020-2021/5781

Enrollment Information

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

- Rabbi Menachem Mendel

Please submit all HSRS 5781 Registration forms by September 1, 2020

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 2020-2021 Academic Year will begin on Sunday. September 13th for all grades. At this time, all classes will be online.

FAMILY INFORMATION

* Primary Adult First Name

* Primary Adult Last Name

* Relationship to Student(s)

* Primary Adult Email

* Primary Adult Cell Phone

Primary Adult Work 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 First Name

Secondary Adult Last Name

Secondary Adult Relationship to Student

Secondary Adult Email Address

Secondary Adult Cell Number

Secondary Business 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 2020

* Please select the grade your child will be enrolling in for the 2020-2021 school year

* Did your child attend Religious School in 2019-2020?

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

Which Religious School did your child attend last year?

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.

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.

* Signature (please write in your name)

Date

* Student’s Physician

* Physician's Address

* Physician's Phone Number

* 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.

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?

NoYes

Student #2 First Name

Student #2 Last Name

Hebrew Name

Date of Birth

MM/DD/YY

Age

Name of Secular School

Grade in Fall 2020

Please select the grade your child will be enrolling in for the 2020-2021 school year

Did your child attend Religious School in 2019-2020?

Yes, HSRSYes, at another school (please indicate below)No

Which Religious School did your child attend last year?

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:

Signature (please write in your name)

Date

Student’s Physician

Physician's Address

Physician's Phone Number

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:

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

Primary Adult Name

Primary Adult Occupation

Since family involvement is a key component of HSRS, we encourage you to sign up for volunteer opportunities. Please select as many as you would like!

Secondary Adult Name

Secondary Adult Occupation

Since family involvement is a key component of HSRS, we encourage you to sign up for volunteer opportunities. Please select as many as you would like!

HSRS Proposed Tuition and Fees 2020-2021


Virtual		Tuition	Registration	Total
Members	K -2nd	$1,035.00	$175.00	$1,210.00
	3rd - 7th	$1,557.00	$175.00	$1,732.00

Non Members	K - 2nd	$1,713.00	$175.00	$3,800.00

In Person
Members	K - 2nd	$1,150.00	$175.00	$1,325.00
	3rd - 7th	$1,730.00	$175.00	$1,325.00

Non Members	K-2nd	$1,903.00	$175.00	$2,078.00

Tuition is billed over 10 months. Registration fee is due now.
ONLINE HSRS rates are subject to change if/when we resume in-person class this year.

Registration Fee Due Now

* $175 Registration Fee Per Child Due Now

Please Select OneRegistration for 1 child ($175)Registration for 2 children ($350)