VOS - J.E.W.E.L.S Ani v Atah Student Application

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1 VOS - J.E.W.E.L.S Ani v Atah Student Application Student Information Name Middle Name Hebrew Name Address Number & Street City Zip Student s Student s Phone Male Female Date of Birth Entering Grade Month Day Year School Name of School District Hebrew School (most recently attended) Name Attended until The Student lives with Both Parents Other Please indicate student T-Shirt size: Youth S, M, L Adult S, M, L 1

2 Parent Information FIRST PARENT Address If different from Student s Address Fax Occupation SECOND PARENT Address If different from First Parent s Address Fax Occupation (We ask for addresses to communicate with you and your child in the most effective and economical way. Your address will not be used for other purposes) I AM CURRENTLY A MEMBER OF VOS I AM ATTACHING AN APPLICATION AND PAYMENT FOR VOS MEMBERSHIP How did you hear about Ani v Atah: VOS Mailing VOS Outreach Publication Friend Cantor Li-Paz s Office Print Ad Electronic Ad Other I hereby give permission to VOS-JEWELS to use my child s photo in its publicity materials. Signature of Parent/Guardian Date 2

3 Medical & Emergency Information - Release Form STUDENT M F Middle Initial Birth Date Height Weight Address Number & Street City Zip FIRST PARENT SECOND PARENT PHYSICIAN Name Phone MEDICAL INSURANCE Company Name Policy #/Medical Record # (Kaiser only) In case of emergency, my child may be released to: (At least one name is required) EMERGENCY CONTACT 1 Name Relation Phone EMERGENCY CONTACT 2 Name Relation Phone Please list existing medical conditions of special concern including, but not limited to, allergies to food or medication Please inform us of any psychological, behavioral, or learning concerns or disabilities. I hereby give permission for my child to participate in all VOS-ANI V TAH programs, activities and events and do release VOS and its representatives from all liability arising out of my child s participation in such activity. In addition, I the undersigned parent/guardian of the above child, do further certify that my child is physically able to participate in such activity and hereby authorize VOS-ANI V TAH and its authorized representatives as agents for the undersigned, to consent that VOS-ANI V TAH seek medical care for my child in a case of a medical emergency. I have read and fully agree to the medical/liability release form above: Signature of Parent/ Guardian Date Signature of Parent/ Guardian Date 3

4 Ani v Atah Tuition Fees for School Year October May (14 two hour meetings dinner included) Tuition $750 VOS Member/ $950 Non-Member (a $50 non-refundable application fee is included in the tuition) Sibling Discount - $50 reduction for each additional child *Jew Crew Teen Youth Group Membership is included in the AVA fee* NEW Keeping Up Your Hebrew Program Mandatory for teens preparing for bar/bat-mitzvah and not yet in private bar/bat mitzvah training. Tuition $165 for 5 week block - must be paid in full at the start of the program *AvA classes are held as near as possible every other week during the school year. Keeping Up Your Hebrew classes will run for an hour every other 'off' week Tuition Due Upon Enrollment *TUITION TWO PAYMENT OPTION* $400 or $500 due upon enrollment - Balance January 1, 2013 *Valid Credit Card on file with the VOS office required for the two payment option Valley Outreach Synagogue Membership $975 (Family Membership) $ 488 (Single Parent with Children) (NOT REQUIRED for participation in Ani v Atah) Please complete separate form for VOS membership and return the VOS membership application form and payment with the Ani v Atah enrollment material (if applicable). VOS application available online at Payment by credit card or check (payable to Valley Outreach Synagogue memo line marked Ani v Atah) Tuition for first child ($750) Non Member Fee ($950) Tuition for additional children Keeping up Your Hebrew -first 5 week course ($165) I am delighted to do the mitzvah of providing a donation for a student scholarship I enclose a check or Please charge my VISA MC $ * Name on card (Total of above) Card # Exp 3 Digits on back Please charge my credit card for future payments. (I grant permission for VOS to keep my credit card information on file) * Please indicate the amount paid at this time to reflect either full payment or payment based on the above-described two payment option. 4

5 Parents/guardians understand that at the sole and absolute discretion of VOS-JEWELS, if it is determined that the scholastic and/or behavioral needs of any student cannot be met by the school, VOS-JEWELS has the right and discretion to require that such a student be withdrawn from the program at any time during the school year. Parents/guardians understand that VOS-JEWELS also reserves the right at its sole and absolute discretion to suspend, dismiss or expel any student as a result of any acts of willfully disruptive behavior. In the event that a student leaves before January1, 2013, VOS reserves the right to withhold a pro-rated portion of the tuition. Students leaving after January 1, 2013, or students who are dismissed from the program due to non-compliance with VOS-JEWELS rules, will not receive a refund. TERMS OF AGREEMENT SCHOOL FEES I have completed the Application for Admission form and have enclosed my enrollment payment. For my tuition payment I have chosen: Payment in full / Two payment plan I have filled out and returned my VOS application form (optional) (Available on line at Signature of Parent/Guardian Date As our synagogue is built on a spirit of volunteerism, we require Ani v'atah parents to contribute time and expertise in at least one of the following areas. Please check at least one box: Host an Interest Meeting Host an AvA class for half or all of the year Coordinate Class Mitzvah Projects Join the Sunshine Committee Help Plan Fundraisers & Community Events Assist at Fundraisers & Community Events Call on an As-Needed Basis Other (please specify) CHECK LIST: completed Ani v Atah application form including: student information/parent information/ medical release/payment details/volunteer form/signed Terms of Agreement (above) completed VOS application form (optional) check for payment of Ani v Atah fee in full or credit card # for two payment option payment for the first 5 week series of Keeping Up With Your Hebrew (if applicable) *IN ORDER FOR A STUDENT TO PARTICIPATE IN A CLASS, ALL OF THE ABOVE ITEMS MUST BE RECEIVED BY THE VOS OFFICE A MINIMUM OF 1 WEEK PRIOR TO THE CLASS. UPON RECEIPT OF ALL THE REQUIRED MATERIALS AND PAYMENT, AN ADMISSION CARD TO BE HANDED TO THE INSTRUCTOR ON THE FIRST DAY OF CLASS WILL BE SENT TO YOU VIA . 5

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