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Religious School 5785 2024-2025 Registration
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Scheck Family Religious School
Wednesday 4:30-6:30pm
Drop off carpool 4:20pm
Pick up carpool 6:30pm
Tuition for the entire 2024-2025 school year is $500 per student with a reduced rate of $450/sibling. Bringing back tuition after waiving it for six years is expanding opportunities for program enhancements in today's new economy. As always, financial aid opportunities and flexible payment plans are available.
Please contact Jill Koch at jkoch@btbrc.org for details.
Credit card payments are subject to approximately 3% merchant processing fee. Payments can be made using an e-
check in order to avoid credit card processing fees.
If you have any questions regarding your payments, please contact Diana Garcia at
dgarcia@btbrc.org
PARENT/GUARDIAN # 1
Parent/Guardian # 1 Title
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Parent/Guardian # 1 First Name
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Parent/Guardian # 1 Last Name
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Parent/Guardian # 1 Address
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Parent/Guardian # 1 City
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Parent/Guardian # 1 State
--Select State--
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
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Parent/Guardian # 1 Zip
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Parent/Guardian # 1 Cell Phone
Parent/Guardian # 1 Work Phone
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Parent/Guardian # 1 E-mail
PARENT/GUARDIAN # 2
Parent/Guardian # 2 Title
Parent/Guardian # 2 First Name
Parent/Guardian # 2 Last Name
Parent/Guardian # 2 Address
Parent/Guardian # 2 City
Parent/Guardian # 2 State
--Select State--
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Parent/Guardian # 2 Zip
Parent/Guardian # 2 Cell Phone
Parent/Guardian # 2 Work Phone
Parent/Guardian # 2 E-mail
*
How many students are you registering?
Please Select One
One
Two
Three
Total
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Please enter the credit card you want to use for payments Provide FULL credit card number - Exp date - sec number
Provide FULL credit card number - Exp date - sec number
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Student # 1 First Name
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Student # 1 Last Name
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Student # 1 Date of Birth
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Student # 1 Grade Level as of September 2024
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Student # 1 Gender
Please Select One
M
F
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Student # 1 lives with
Please Select One
Both Parents
Mother
Father
Other
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If Other, Please Explain
MEDICAL INFORMATION
Student is allergic to
Treated with
Reaction
List Any Medications Your Child is Taking
*
Student # 2 First Name
*
Student # 2 Last Name
Student # 2 Date of Birth
*
Student # 2 Grade Level as of September 2024
*
Student # 2 Gender
Please Select One
M
F
*
Student # 2 lives with
Please Select One
Both Parents
Mother
Father
Other
*
If Other, Please Explain
MEDICAL INFORMATION
Student is allergic to
Treated with
Reaction
List Any Medications Your Child is Taking
*
Student # 3 First Name
*
Student # 3 Last Name
Student # 3 Date of Birth
*
Student # 3 Grade Level as of September 2024
*
Student # 3 Gender
Please Select One
M
F
*
Student # 3 lives with
Please Select One
Both Parents
Mother
Father
Other
*
If Other, Please Explain
MEDICAL INFORMATION
*
Student is allergic to
Treated with
Reaction
List Any Medications Your Child is Taking
EMERGENCY CONTACT #1
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Emergency Contact # 1 Full Name
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Emergency Contact # 1 Relationship
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Emergency Contact # 1 Cell Phone
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Emergency Contact # 1 Alt. Phone Number
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Emergency Contact # 1 E-mail Address
EMERGENCY CONTACT #2
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Emergency Contact # 2 Full Name
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Emergency Contact # 2 Relationship
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Emergency Contact # 2 Cell Phone
*
Emergency Contact # 2 Alt. Phone Number
*
Emergency Contact # 2 E-mail Address
Individuals Who Can Pick Up the student (s)
First Name
Last Name
Relationship
First Name
Last Name
Relationship
First Name
Last Name
Relationship
Individuals Who Can NOT Pick Up the student (s)
First Name
Last Name
Relationship
First Name
Last Name
Relationship
First Name
Last Name
Relationship
MEDICAL RELEASE
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Please Type Name of Parent/Guardian to Sign
I declare that I have provided Beth Torah Adath Yeshurun Inc, DBA Beth Torah Benny Rok Campus and Scheck Family Religious School with all information regarding my child(ren)'s health, which may reasonably be needed to meet the medical and/or physical needs of my child(ren). I further agree that I can be reached at the telephone number(s) I have provided during the hours my child(ren) is/are at Beth Torah Benny Rok Campus. If an emergency arises, and none of the above numbers can be contacted for any reason, I hereby authorize Beth Torah Adath Yeshurun Inc, DBA Beth Torah Benny Rok Campus to seek emergency medical treatment administered by, but not restricted to, paramedics, hospital emergency room employees, and/or other medical professionals as reasonably necessary for the emergency medical treatment of my child(ren). I hereby release Beth Torah Adath Yeshurun Inc, DBA Beth Torah Benny Rok Campus and its staff members from any liability resulting from any medical services provided and agree to pay for such services upon invoice. I understand that the resulting expenses will be my responsibility and not the responsibility of Beth Torah Adath Yeshurun Inc, DBA Beth Torah Benny Rok Campus.
PHOTO RELEASE
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Name of Child/Children
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Please Type Name of Parent/Guardian to Sign
I agree to allow my child’s name, photograph, and information to be used by Beth Torah Benny Rok Campus and Scheck Family Religious Schools in the programs' publications, videos, promotional materials social media and website, without compensation and without prior notice. I release and hold the school harmless from any liability stemming from the use of my child’s name, photograph, or information.
RECORDS RELEASE
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Name of Child/Children
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Please Type Name of Parent/Guardian to Sign
I agree to allow my child’s name, photograph, and information to be used by Beth Torah and The Scheck Family Religious School publications, videos, promotional materials social media and website, without compensation and without prior notice. I release and hold the school harmless from any liability stemming from the use of my child’s name, photograph, or information.
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Please Type Name of Parent/Guardian to Sign
I understand that all students must provide updated vaccine records to the Scheck Family Religious School office prior to the first day of school. ALL STUDENTS attending the Scheck Family Religious Program MUST be fully immunized as of the first day of school. Religious School does not accept religious exemptions. To the extend that you believe that your child is medically exempt, that exemption will be considered on a case-by-case basis.
Parent Handbook Acknowledgement. Please Type Name of Parent/Guardian to Sign
Parent Handbook 5785
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Please initial below that you have read the Beth Torah Adath Yeshrun Inc. - DBA Beth Torah Benny Rok Campus , and I understand and agree to comply with all of the conditions stated herein.
Grand Total
Thu, January 2 2025 2 Teves 5785
