Gesher Registration - Temple Anshe Hesed

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Temple Anshe Hesed - Gesher Program Registration 2023-2024~ 5784

Jewish education has always been a priority for Temple Anshe Hesed. Our congregation is deeply committed to ensuring that every Jewish child receives an outstanding Jewish educational experience. We are grateful that our Temple leadership continues to subsidize each student in our Gesher Program with $500 tuition assistance.

Please sign into your Temple Account before completing the online registration. If you need assistance with this, please contact the Temple office at 814-454-2426.

If you have applied for scholarship funding for your child(ren), please choose the "bill my account" option at time of submission and the Temple office will contact you. Thank you!

Family Name

STUDENT INFORMATION

How many students are being registered?

STUDENT 1 INFORMATION

Student 1 - Class

Student 1 - Name

Student 1 - Hebrew Name

Student 1 - Date of Birth

Student 1 - Secular Grade

Student 1 - Secular School

Student 1 - Preferred Pronoun

(i.e. he, him, his, she, her, hers, they, them, theirs)

Student 1 - Allergies

Student 1 - Health Concerns

Student 1 - Special Needs

If your child has an accommodation plan or an IEP, please share this with the Gesher Coordinator.

STUDENT 2 INFORMATION

Student 2 - Class

Student 2 - Name

Student 2 - Hebrew Name

Student 2 - Date of Birth

Student 2 - Secular Grade

Student 2 - Secular School

Student 2 - Preferred Pronoun

(i.e. he, him, his, she, her, hers, they, them, theirs)

Student 2 - Allergies

Student 2 - Health Concerns

Student 2 - Special Needs

If your child has an accommodation plan or an IEP, please share this with the Gesher Coordinator.

STUDENT 3 INFORMATION

Student 3 - Class

Student 3 - Name

Student 3 - Hebrew Name

Student 3 - Date of Birth

Student 3 - Secular Grade

Student 3 - Secular School

Student 3 - Preferred Pronoun

(i.e. he, him, his, she, her, hers, they, them, theirs)

Student 3 - Allergies

Student 3 - Health Concerns

Student 3- Special Needs

If your child has an accommodation plan or an IEP, please share this with the Gesher Coordinator.

PARENT INFORMATION

* Parent/Guardian 1 - First Name

* Parent/Guardian 1 - Last Name

* Parent/Guardian 1 - Email Address

* Parent/Guardian 1 - Cell Phone

* Parent/Guardian 1 - Address

* Parent/Guardian 1 - City

* Parent/Guardian 1 - State

* Parent/Guardian 1 - Zip Code

Parent/Guardian 1 - Home Phone

Is there a second Parent/Guardian?

* Parent/Guardian 2 - First Name

* Parent/Guardian 2 - Last Name

* Parent/Guardian 2 - Email Address

* Parent/Guardian 2 - Cell Phone

Does parent/Guardian 2 live at the same address as Parent/Guardian 1?

Parent/Guardian 2 - Address

Parent/Guardian 2 - City

Parent/Guardian 2 - State

Parent/Guardian 2 - Zip Code

Parent/Guardian 2 - Home Phone

MEDICAL INFORMATION

Physician Name:

Phone Number:

Insurance Company:

Policy / ID#:

EMERGENCY CONTACT INFORMATION

Please list two persons other than parents that can be contacted in the event of an emergency.

* Emergency Contact 1 - Name

* Emergency Contact 1 - Phone Number

* Emergency Contact 1 - Relationship to Student

Emergency Contact 1 - My child(ren) may be released to this person.

* Emergency Contact 2 - Name

* Emergency Contact 2 - Phone Number

* Emergency Contact 2 - Relationship to Student

Emergency Contact 2 - My child(ren) may be released to this person.

The following people may pick-up my child(ren):

RELEASE INFORMATION

* Please check to confirm all boxes below:

Press Release: I grant the Gesher Program of Temple Anshe Hesed permission to take photographs / videos of my child(ren) in connection with Gesher School events. I agree that Temple Anshe Hesed Gesher Program may use this consent for such purposes as newsMedical Release: In the event of a medical emergency or injury, I authorize Temple Anshe Hesed to administer First Aid and/or transport for my child(ren) if a parent, guardian, or emergency contact cannot be reached.Grounds Release: I authorize my child to participate in any class-time activity, including anything that may take place outside the building (but still on Temple Anshe Hesed property) without prior notice.

Total Tuition Fees

Please click the submit button below to make payment arrangements.

Tue, April 23 2024 15 Nisan 5784