Yesod Program Enrolment Form

Student Details

* Surname

* First Name

Gender

* Date of Birth

* Date of Bar/Bat Mitzvah (if known)

* Primary School

* High School (if known)

Current school year

Student First Hebrew Name

Father's First Hebrew Name

Only if Jewish

Mother's First Hebrew Name

Only if Jewish

Preferred Class Session

Preferred day of attendance

Sundays 10:00am-11:30am, in-person at Emanuel SynagogueMondays 4:00pm-5:30pm, in-person at Emanuel SynagogueTuesdays 4:00pm-5:30pm, Online (for long-distance students)Please select up to two options

Parent Details

Full Name of Parent 1

Full Name of Parent 2

* Email of Parent 1

* Email of Parent 2

* Mobile of Parent 1

* Mobile of Parent 2

Home Address (street)

Suburb

* Post Code

Emergency Contact and Medical Information

Family Medicare No

Private Health Fund

Private Health Fund Number

Name of GP

Phone number of GP

Address of GP (street, suburb)

Is your child on regular medication? If so, please advise.

If none, please write N/A.

Does your child suffer from any allergies? If so, please advise.

If none, please write N/A.

Does your child have any medical conditions? If so, please advise.

If none, please write N/A.

* MEDICAL CONSENT

In the event of an emergency involving my child I give my consent for Emanuel Synagogue (Hebrew & Religion School) to seek and administer the appropriate medical care at my expense, with the understanding that I will be notified as soon as possible of any such incident.

Permissions

* PHOTO PERMISSION

I give permission for my child’s photos or student work, including my child/children’s names, to be used in communications about the Yesod Program (Emanuel Synagogue Beit Midrash). This may include publicity in Emanuel Synagogue newsletters, the Australian Jewish News, the Emanuel Synagogue website and other similar publications.

* WITHDRAWAL FROM PROGRAM

Parents must notify the school if their child is withdrawn from the Yesod Program (Emanuel Synagogue Beit Midrash) for any reason at any time. In the event of my child leaving the Beit Midrash I agree to notify the Head of Youth Education, by email or in writing, prior to the commencement of the next term.

* RELEASE AND INDEMNITY

I agree that neither Emanuel Synagogue, Emanuel Synagogue Beit Midrash, nor the Board of Progressive Jewish Education (BPJE) will be responsible for any injury or loss which my child may suffer while attending the school. I accordingly hereby release Emanuel Synagogue, Emanuel Synagogue Beit Midrash and BPJE, as well as any of its officers, staff (both administrative and nonadministrative) from any liability for any such injury or loss and indemnify each of them against all actions, claims or proceedings which may be brought against all or any of them by reason thereof.

Acknowledgement of Above Sections

Full Name of Parent/Guardian

* Upload digital signature

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Payment Section

The cost per term is $330. Please note that you will be automatically billed each term to the credit card details provided below, unless you have provided written notification of intended withdrawal as per point number 2 under permissions above.

Credit Card Number

Expiry Date

CCV