Journey Registration 2020-21 - Form

Parent/Guardian Information

* Parent #1 First Name:

* Parent #1 Last Name:

Parent #2 First Name:

Parent #2 Last Name:

We will communicate by both email and text.

* Phone Number Parent #1:

Phone Number Parent #2

* Email Address Parent #1

Email Address for Parent #2

Child Information

* Child's First Name:

* Child's Last Name:

Child's Hebrew Name:

* Child's Birthdate

* Child's Gender

* Local Emergency Contact Name:

* Local Emergency Contact Phone Number:

* Please list the names of adults (other than parents/guardians), who have permission to pick up your child from Journey:

Separate names with commas.

Child's Medical Information

* Please tell us about any medical issues your child has that could impact them during their time with us.

* Is your child on any medicines that need to be administered or may alter their behavior during their time at Journey?

* Does your child have any allergies to foods or other things that they may come into contact with during their time at Journey?

Is their anything else we should know about your child to help assure their safety during Journey activities?

Do we have permission to administer the following over-the-counter medicines to your child according to package labeling should your child become ill?

Tylenol (aceptaminophen)Motrin (Ibuprofin)Benadryl (diphenylhydramine)

Check all that apply.

***Please email a copy of your child's current immunization records to Holly Hunsicker

* By typing my name below, I acknowledge that I am a legal parent/guardian for the child above, and in case of medical emergency, give permission for my child to receive first aid.

Tuition

* Please select tuition amount from options below:

PLEASE NOTE: When you submit this form, you will be prompted to make an immediate payment via a credit/debit card OR have your child's tuition billed to your account.

If you are signed into your account, you can set up a payment plan by choosing the option above and click on how often you would like to be billed.

If you are not signed into your account, and you choose the "bill my account" option, please submit and then click on "my account" at the top of your screen. You will be prompted to set up a payment plan on a schedule that works for you starting between now and five days from now. If you need longer than five days to make your first payment, please simply revisit the "my account" section when you are ready to set up your payment plan. If you want to pay by check, select Bill my Account" and submit your check to Shma Koleinu PO Box 1808 Bellaire, TX 77402

* Please select how you would like to pay:

I am interested in learning more about financial-need scholarships for Journey.

We Need You!

We are always looking for volunteers to help lead, facilitate and participate Journey program events.

Do you like to work with kids? Can you read Hebrew (sound out consonants and vowels)? How about working with teenagers? Are you artistic? Do you like gardening? Can you sing or play guitar? Can you cook/bake?

If you have any of these (or other!) talents, please let us know in the space below.

Note: All adult teachers (volunteer and paid) will be required to undergo a background check.

Tell us a little about yourself. How would you like to be involved in the Journey Program? (optional)

Thank you for enrolling your child in Journey, the Jewish Discovery Project at Shma Koleinu!

To enroll an additional child, please complete a separate registration form.

We look forward to seeing you in the fall!

- The Shma Koleinu Journey Team