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By choosing either Beth Shalom or Rodef Shalom as your home synagogue to receive the member tuition rate, you must:
- be a current member in good standing of either congregation
- and be the legal guardian of the student(s) being enrolled.
*
Indicates Response Required
What is your home synagogue?
*
Beth Shalom
Rodef Shalom
Other Affiliation
Unaffiliated
Which synagogue did/do you belong to?
Are you interested in receiving membership information from either Rodef Shalom or Beth Shalom?
*
Yes, Rodef Shalom
Yes, Beth Shalom
No
Student Information
Student 1
Student's Preferred First Name
*
Student Last Name
*
Hebrew Name
Birth Date
*
+
Pronouns
*
🛈
she / her / hers
he / him / his
they / them / theirs
Not listed (please share in next question)
No preference
No pronoun
Prefer not to share
Pronouns (if not listed)
Grade as of 9/2023
*
K
1
2
3
4
5
6
7
8
9
10
11
12
Student's Secular School
*
Student Email
Student Cell Phone
Attends Jewish overnight camp at...
Register another student?
Yes
Student 2
Student's Preferred First Name
Student Last Name
Hebrew Name
Birth Date
+
Pronouns
🛈
she / her / hers
he / him / his
they / them / theirs
Not listed (please share in next question)
No preference
No pronoun
Prefer not to share
Pronouns (if not listed)
Grade as of 9/2023
K
1
2
3
4
5
6
7
8
9
10
11
12
Student's Secular School
Student Email
Student Cell Phone
Attends Jewish overnight camp at...
Register another student?
Yes
Student 3
Student's Preferred First Name
Student Last Name
Hebrew Name
Birth Date
+
Pronouns
🛈
she / her / hers
he / him / his
they / them / theirs
Not listed (please share in next question)
No preference
No pronoun
Prefer not to share
Pronouns (if not listed)
Grade as of 9/2023
K
1
2
3
4
5
6
7
8
9
10
11
12
Student's Secular School
Student Email
Student Cell Phone
Attends Jewish overnight camp at...
Register another student?
Yes
Student 4
Student's Preferred First Name
Student Last Name
Hebrew Name
Birth Date
+
Pronouns
🛈
she / her / hers
he / him / his
they / them / theirs
Not listed (please share in next question)
No preference
No pronoun
Prefer not to share
Pronouns (if not listed)
Grade as of 9/2023
K
1
2
3
4
5
6
7
8
9
10
11
12
Student's Secular School
Student Email
Student Cell Phone
Attends Jewish overnight camp at...
Family Information
Parent/Guardian 1 (where student resides)
First Name
*
Last Name
*
Address
*
City
*
State
*
Zip
*
Home Phone
Cell Phone
*
Email
*
Parent/Guardian 2
First Name
Last Name
Address (if different)
City, State, Zip (if different)
Home Phone (if different)
Cell Phone
Email
Grandparent Information (Optional - to receive weekly J-JEP email updates)
Grandparent Name(s)
Grandparent(s) Email
Grandparent Name(s)
Grandparent(s) Email
Please List Two "In-Case of Emergency" Individuals. *These individuals may be contacted if unable to reach a parent, or are authorized for student pick-up.*
Name
*
Phone/Cell Phone #
*
Relationship
*
Name
*
Phone/Cell Phone #
*
Relationship
*
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