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Beit Sefer Phyllis Mintzer 2021-2022 School Year Registration
Student 1
*
Student 1: Name
Student's Hebrew Name (if applicable)
*
Birthdate
*
Gender
Female
Male
Non-binary/ third gender
Prefer not to say
Prefer to self-describe (you may do so in the space provided)
Self-description
Sha'ar Zahav embraces all gender identities
*
Grade in Fall 2021
*
Name of Public or Private School
*
I am enrolling this child to attend:
Please Select One
In-Person Beit Sefer
On-line Beit Sefer
When circumstances (vaccination, family move, other safety issues) change, students may change from in-person to on-line or vice versa. They may not change week by week; they must choose a learning setting.
Student 2
Student 2: Name
Student's Hebrew Name (if applicable)
Birthdate
Gender
Female
Male
Non-binary/ third gender
Prefer not to say
Prefer to self-describe (you may do so in the space provided)
Self-description
Sha'ar Zahav embraces all gender identities.
Grade in Fall 2021
Name of Public or Private School
I am enrolling this child to attend:
In-Person Beit Sefer
On-line Beit Sefer
When circumstances (vaccination, family move, other safety issues) change, students may change from in-person to on-line or vice versa. They may not change week by week; they must choose a learning setting.
Student 3
Studernt 3: Name
Student's Hebrew Name (if applicable)
Birthdate
Gender
Female
Male
Non-binary/ third gender
Prefer not to say
Prefer to self-describe (you may do so in the space provided)
Self-description
Sha'ar Zahav embraces all gender identities.
Grade in Fall 2021
Name of Public or Private School
I am enrolling this child to attend:
In-Person Beit Sefer
On-line Beit Sefer
When circumstances (vaccination, family move, other safety issues) change, students may change from in-person to on-line or vice versa. They may not change week by week; they must choose a learning setting.
Parent 1
*
First Name
*
Last Name
*
Email
*
Gender
Female
Male
Non-binary/ third gender
Prefer not to say
Prefer to self-describe (you may do so in the space provided)
Self-description
Sha'ar Zahav embraces all gender identities
*
Primary Phone
Secondary Phone
*
Street Address
Address Line 2
*
City
*
State
--Select State--
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
*
Zip Code
Parent 2
First Name
Last Name
Email
Gender
Female
Male
Non-binary/ third gender
Prefer not to say
Prefer to self-describe (you may do so in the space provided)
Self-description
Sha'ar Zahav embraces all gender identities
Primary Phone
Secondary Phone
Street Address
Address Line 2
City
State
--Select State--
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip
Medical and Emergency Information
Emergency Information
Person other than parent to contact in case of emergency (mandatory to list at least one, two is better!)
*
First Name
*
Last Name
*
Relationship
*
Phone
First Name
Last Name
Relationship
Phone
Medical Information
*
Physician's Full Name
*
Physician's Phone
*
Health Insurance Company
*
Policy Number
*
Re-type Policy Number
Does your child have life threatening allergies?
*
If so, please state the name of the child you are referring to and provide a description in the space provided. If not, please type "No" or N/A"
Does your child have any other allergies or other important medical information you'd like us to be aware of?
*
If so, please state the name of the child you are referring to and provide a description in the space provided. If not, please type "No" or N/A"
*
Does your child have special accommodations in public or private school?
Please Select One
No
Yes
If you checked off yes, please state the name of the child you are referring to. The Director of Education will contact you to learn more. This will allow us to create a successful learning environment for your child.
Medical Consent
*
I, the undersigned, authorize Sha’ar Zahav to call a physician or seek emergency room treatment as necessary for any of my children in case of any medical emergency and agree to pay all expenses incurred. (This authorization is given pursuant to the provisions of section 25.8 of the Civil Code of the State of California)
Please Select One
Yes
Field Trip Permission
*
I authorize my child(ren) to attend all planned trips arranged by youth education programs at Congregation Sha’ar Zahav, and release Sha’ar Zahav, its officers, agents and employees from any and all liability arising out of my child’s participation in such activity.
Please Select One
Yes
No
Photograph Consent
*
Occasionally photos of your student might be included on our web site or other Sha’ar Zahav/Beit Sefer Phyllis Mintzer printed publications. Images will never include any name or other identifying information. Please sign in the space below to give us your consent to publish in print, electronic, or video format the likeness or image of your child(ren)
Please Select One
Yes
No
Enrollment Agreement
*
I understand that I am committing to my child's enrollment in Beit Sefer Phyllis Mintzer for the 2021-2022 school year. I also understand that in order to enroll children in 4th grade and higher, a family commitment to membership is required. I agree to make a membership contribution/"gift of the heart" along with paying the tuition below. There are no refunds on school tuition.
Please Select One
Yes
Payment
BSPM Tuition for Shabbat School Year 2021-2022 (Grades K-7)
$975.00 Per Student
Hebrew Tutoring for School Year 2021-2022 (Grades 5 & 6 ONLY)
$300.00 Per Student
B'nei Mitzvah Fee (Grade 7 ONLY)
$500 Per Student
If you wish to pay in installments, you will be prompted to choose the frequency of payments after clicking "Submit"
Please list the quantity (number of children) you wish to enroll for each program, below.
*
BSPM 2021-2022 School Year Tuition
0
1
2
3
4
5
6
7
8
9
10
Shabbat School for 2021-2022 (Grades K-7)
0
1
2
3
4
5
6
7
8
9
10
Hebrew Tutoring for 2021-2022 (Grades 5 & 6 only)
0
1
2
3
4
5
6
7
8
9
10
B' Mitzvah Fee (Grade 7 only)
0
1
2
3
4
5
6
7
8
9
10
Scholarship
If you require a scholarship, please select the scholarship option only.
A scholarship form will be sent to you; you will be billed after the scholarship is awarded.
Total
Sun, September 19 2021
13 Tishrei 5782
Friday Night
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: 6:46pm
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Havdalah
: 7:52pm
Candle Lighting
Monday, Sep 20, 6:52pm
Havdalah
Tuesday, Sep 21, 7:58pm
Erev Sukkot
Monday, Sep 20
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Sun, September 19 2021 13 Tishrei 5782
