Machon Micah K-7th Registration Form (2012-2013)

Registration is now open for Machon Micah for 2012-2013. Families enrolling a child for the first time in Machon Micah need to attend a new parent orientation meeting with our education director, Deborah Srabstein, before filling out a registration form.  Deborah can be reached at educationdirector@templemicah.org.

This year, we have three registration deadlines, which are detailed below. We ask that you please register as early as possible, as it makes our planning so much easier.

"Fully completed registration" means that

A. Paperwork has been submitted in the online form below AND

B. Payment has been been arranged in one of the following three ways:

1. A check for full payment has been received by the office before the registration date. (Checks "in the mail" by the registration date don't count!)
2. Credit card information has been submitted via the registration form OR by phone to Leonard Tow ( 202-342-9175).  Credit card payments will take place in six installments, from October through March.
3. If you need to discuss alternate financial arrangements, please contact our executive director, Rachel Gross, at 202-342-9175.  Please note: Rachel will be out of the office from August 24th to September 3rd, so please plan accordingly if you wish to make a certain registration deadline!

The three registration deadlines are August 6th, August 19th, and September 4th.

• Families who have fully completed registration by Monday, August 6th will be given early access to the Skype tutoring sign-up sheet on Monday, August 13th.
• Families who have fully completed registration by Friday, August 19th  will receive access to the Skype tutoring sign-up sheet on Thursday, August 23rd.
• Families who have fully completed registration by Tuesday, September 4th will receive access to the Skype tutoring sign-up sheet on Friday, September 7th.

Parent/Guardian #1

Parent/Guardian #1 Name (Required)

first name, last name

Street Address (Required)

City (Required)

State (Required)

DC
MD
VA

Zip Code (Required)

Home phone (Required)

Work phone (Required)

Cell phone (Required)

Email Address (Required)

Second Email Address

optional

Parent/Guardian #2

Parent/Guardian #2 Name

first name, last name

Street address is the same as parent/guardian #1

if not, please fill out information below

Street Address

City

State

DC
MD
VA

Zip Code

Home phone

if different from parent/guardian #1

Work phone

Cell phone

Email Address

Second Email Address

optional

Emergency Contacts

other than parents/guardians

Emergency Contact #1 Name (Required)

Relationship (Required)

Home phone (Required)

Cell phone (Required)

Emergency Contact #2 Name (Required)

Relationship (Required)

Home phone (Required)

Cell phone

Child #1

Child #1 Name (Required)

first name, last name

Gender (Required)

M
F

Birthday (Required)

Child's address

indicate parent/guardian with whom the child lives.

Parent/Guardian #1
Parent/Guardian #2

Name of secular school

Grade in secular school (2012-2013)

If different from grade at Temple Micah

Kindergarten 1st Grade 2nd Grade 3rd Grade 4th Grade 5th Grade 6th Grade 7th Grade 8th Grade

Child #1 Grade at Temple Micah (Required)

Kindergarten 1st Grade 2nd Grade 3rd Grade 4th Grade 5th Grade 6th Grade 7th Grade

Child #1 Health Information

General Health

Please list general health condition, including any vision, speech, or hearing issues, any specific physical condition or illness - past or present

Special Diet or Food Allergies

This information will be provided to all teachers on staff, and will also be posted in the kitchen. We do not want to treat this information confidentially because we want it to be as widely available as possible.

Prescription Medication

if any, provide name and purpose of each medication

Child #1 Other Information

What do you perceive your child's strengths to be?

What do you perceive your child's challenges to be? If there are specific strategies that work well in school, please share them. If your child has unique learning needs, please share them.

Child #2

Child #2 Name

first name, last name

Gender

M
F

Birthday

Child's address

indicate parent/guardian with whom the child lives.

Parent/Guardian #1
Parent/Guardian #2

Name of secular school

Grade in secular school (2012-2013)

If different from grade at Temple Micah

Kindergarten 1st Grade 2nd Grade 3rd Grade 4th Grade 5th Grade 6th Grade 7th Grade 8th Grade

Grade at Temple Micah

Kindergarten 1st Grade 2nd Grade 3rd Grade 4th Grade 5th Grade 6th Grade 7th Grade

Child #2 Health Information

General Health

Please list general health condition, including any vision, speech, or hearing issues, any specific physical condition or illness - past or present

Special Diet or Food Allergies

This information will be provided to all teachers on staff, and will also be posted in the kitchen. We do not want to treat this information confidentially because we want it to be as widely available as possible.

Prescription Medication

if any, provide name and purpose of each medication

Child #2 Other Information

What do you perceive your child's strengths to be?

What do you perceive your child's challenges to be? If there are specific strategies that work well in school, please share them. If your child has unique learning needs, please share them.

Child #3

Child #3 Name

first name, last name

Gender

M
F

Birthday

Child's address

indicate parent/guardian with whom the child lives.

Parent/Guardian #1
Parent/Guardian #2

Name of secular school

Grade in secular school (2012-2013)

If different from grade at Temple Micah

Kindergarten 1st Grade 2nd Grade 3rd Grade 4th Grade 5th Grade 6th Grade 7th Grade 8th Grade

Grade at Temple Micah

Kindergarten 1st Grade 2nd Grade 3rd Grade 4th Grade 5th Grade 6th Grade 7th Grade

Child #3 Health Information

General Health

Please list general health condition, including any vision, speech, or hearing issues, any specific physical condition or illness - past or present

Special Diet or Food Allergies

This information will be provided to all teachers on staff, and will also be posted in the kitchen. We do not want to treat this information confidentially because we want it to be as widely available as possible.

Prescription Medication

if any, provide name and purpose of each medication

Child #3 Other Information

What do you perceive your child's strengths to be?

What do you perceive your child's challenges to be? If there are specific strategies that work well in school, please share them. If your child has unique learning needs, please share them.

Additional Information

Health Care Information

Medical Insurance Name

Physician's Name

Physician Phone number

Dentist's Name

Dentist Phone number

Liablilty Release Agreement

Liablilty Release Agreement

I, the undersigned, request permission for the above students to participate in the various activities of Machon Micah. I understand the student(s) may take part in Machon Micah activities occurring on its premises, as well as, outside its premises. I know the risks and hazards involved in the said activities, and that anticipated and unexpected injuries may arise during such activities. I assume all risks of injury to the student(s) person and property that may be sustained in connection with these activities. I understand that it is not the function of the Machon Micah, its agents, servants, employees, instructors and officers to guarantee the safety of the participant with respect to these activities. I also understand that the student(s) has the responsibility to exercise due care for all participants safety in the performance of these activities. In consideration of the student(s) being permitted to enroll and participate in these activities, I do hereby release, discharge, indemnify, and hold harmless Machon Micah, its agents, servants, employees, instructors, and officers, and all other participants in the stated activities, of and from all claims, demands, actions, and causes of action of any sort for injuries sustained by the student(s) as a result of or relating to these activities.

Agreement (Required)

I agree to the above statement

Date (Required)

---- 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 / ---- January February March April May June July August September October November December / ---- 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

Parent/Guardian Name (Required)

first name, last name

Photo Release Agreement

Photo Release

Temple Micah occasionally photographs its members, including children, engaged in Micah-related activities. Unless you withhold your permission by indicating below, you consent to Temple Micah using such photographs for appropriate Temple Micah purposes, including Temple Micah's website, newletter and facebook page.

Agreement (Required)

I agree to the above statement
I do not agree to the above statement

Date (Required)

---- 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 / ---- January February March April May June July August September October November December / ---- 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

Parent/Guardian Name (Required)

first name, last name

Carpool/Bus Release Agreement

Carpool/Bus Release Agreement

I hereby acknowledge that my child(ren) may ride on any bus or in any carpool arranged by Temple Micah. If and when the behavior of my child(ren) becomes too distracting for the others on or the driver of the van, I acknowledge that she or he will be asked to find other transportation. In consideration of the opportunity for my child to participate and fully recognizing that such as undertaking involves an element of risk, we assume all risks and hazards incidental to such participation and do hereby release, absolve, indemnify, and agree to hold harmless Temple Micah, nor any of said persons shall be held financial responsible for any injury, illness or death as a direct or indirect result of this activity.

Agreement (Required)

I agree to the above statement
I do not agree to the above statement

Date (Required)

---- 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 / ---- January February March April May June July August September October November December / ---- 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

Parent/Guardian Name (Required)

first name, last name

Payment Options

Please choose how you would like to pay

Payment Options (office code: 232013) (Required)

I will send in one check to cover the cost for the year. If paying in full by check, the fee is $645 for K-2nd grade; $830 for 3rd grade; $985 for 4th-7th grade.
Please charge my credit card in six equal installments, from October through March. The fee for payment by credit card is $660 for K-2nd; $850 for 3rd; $1005 for 4th-7th.
I have made alternate arrangements with executive director Rachel Gross. (The form needs to be submitted AFTER the arrangements have been made.)

Name on Credit Card

Credit Card Number

Credit Card Expiration Date

mm/yyyy

Credit Card Security Code

My billing address is the same as Parent/Guardian #1's address

Yes
No

If no, please enter the billing address