Please enable JavaScript in your browser to complete this form. 11301 W. Broward Boulevard, Plantation, FL 33325 954-472-3600/ Fax 954-472-3622 ramatshalom@ramatshalom.orgPlease indicate which program you are selecting. Please submit one form for each child!Atid (Kindergarten-2nd Grade)Machar (3rd Grade-5th Grade)Child's Name: *Hebrew Name: *Phone: *Email: *School: *Grade in School 2022-2023: *Torah School Grade: *Date of Birth: *Age on 8/1/22: *Identified Gender: *Parent 1 Name: *Parent 2 Name: Parent 1 Phone: *Parent 2 Phone:Parent 1 Work Phone: *Parent 2 Work Phone:Parent 1 Email: *Parent 2 Email:Child lives with:Parent 1Parent 2BothOtherRelationship:Emergency Information: In case of minor illness or injury of my child at school, I give the school staff permission to give basic first aid to my child. In case of a major injury or illness, I understand that staff will make every effort to contact me. If they are unable to do so, I give permission for my child’s physician and/or an ambulance to be contacted and for a physician to hospitalize and/or secure proper treatment for my child.In case of an emergency call:Emergency Contact 1 Name: *Emergency Contact 2 Name:Emergency Contact 1 Phone: *Emergency Contact 2 Phone:Emergency Contact 1 Reltionship: *Emergency Contact 2 Reltionship:My child may be picked up from Torah School by the following people:Pickup List Name 1:Pickup List Name 2:Pickup List Phone 1:Pickup List Phone 2:Pickup List Relationship 1:Pickup List Relationship 2:List any allergies, medical conditions and/or daily medication: (Please notify the Torah School office of any changes)Allergies:Medical Conditions:Medication:Please provide any information about your child that may affect the classroom learning:For example, specific learning issues, special needs, or educational accommodations.Insurance Company:Policy Number:1. Electronic Items: Ramat Shalom is not responsible for any phones or games brought to school. We therefore suggest that you do not bring these items.2. Publicity Release: I authorize pictures and/or videos of my child to be used for publicity and marketing purposes on the Ramat Shalom website, newspapers, magazines, social media, or marketing materials.YesNoElectronic Signature: *Date: *Submit
