TIFERETH ISRAEL CONGREGATION

7701 16th ST. NW, Washington DC 20012

202-882-1605 ext.105 TILearning1@tifereth-israel.org

THE PAUL & ANNETTA HIMMELFARB RELIGIOUS SCHOOL

REGISTRATION 2010-11
(Please type or print clearly)
Student Name: Home Phone:

Address: Student’s Email:

Date of Birth: Student’s Cell Phone:

Gender: Himmelfarb Grade 2010-11:
Secular School Name: Secular Grade 2010 -11:

First Parent Name: Home Phone (if different):

Address (if different): Office Phone:

Cell Phone: Email:

Second Parent Name: Home Phone (if different):

Address (if different): Office Phone:

Cell Phone: Email:

Emergency Contact: Emergency Contact Phone:

(other than parent) (Cell preferred)
Physician’s Name: Physician’s Phone:

Dentist’s Name: Dentist’s Phone:

Synagogue Affiliation? _______________________ Is Father Jewish? ______ Is Mother Jewish? ______

If you were referred to our program by someone, please list his/her name here: ________________________
AUTHORIZATIONS
1. Tifereth Israel has my permission to use my child’s name and photos of my child in TI publications, the TI
website, and community publications.

2. I hereby authorize the supervisory person present to grant approval for and/or to administer first aid and/or
to take my child to a physician or hospital for emergency treatment in the event it appears necessary. I
understand that every attempt will be made to reach me first. I hereby release the congregation and all of the
people associated with this program from any and all liability for injury and/or damages arising out of or as a
result of my child's participation in this program.

____________________________________________________ _____________________
Parent's/Guardian's Signature Date
School Registration – Student Name(s): _____________________________________________________

Member Non-Member Total

Program Grade When # Early Timely Early Timely
(by 7/30/10) (by 7/30/10)
Gan, Aleph K, 1st Sunday
$645 $710 $865 $980
& Bet & 2nd 9:15 am - 12:15pm
Gimel, 3rd- 6th Sunday
Daled, Hay, 9:15 am - 12:15 pm &
$860 $946 $1680 $1890
Vav Wed
4:15 - 6:15 pm
th
Zayin 7 Sat 9:15 am -12:15 pm
$860 $946 $1680 $1890
& Wed 4:15 - 6:15 pm
Chai 8th -12th Wednesday
$620 $682 $735 $830
School 6:15 - 8:15 pm
Book and Activities Fee (covers books, field
$75 $75 $75 $75
trips, special projects, snacks and activities)
Member of another synagogue
$75 $75
(TI rate plus $75)
Discount for additional child(ren) in Gimel, Daled,
-$70 -$70
Hay, Vav or Zayin
Optional: Sponsor school snack in honor of
$25 $25 $25 $25
your child (i.e. birthday)*
Optional: Sponsor Dinner for Chai School
$100 $100 $100 $100
(birthday, special event or for fun)*
Optional: Donation to support the Himmelfarb
School
Total:

*We will contact you for more information.

PAYMENT PROCEDURES
Members
1. For early registration rates, send this application and full payment by July 30th OR for regular rates, send
this application with _ of total due by Friday, Aug. 20th. Balance due by Dec. 31st.
2. For all, _ of annual Tifereth Israel dues must also be paid prior to Aug. 20th to complete registration.

Non-members
Send this application with a deposit of _ the total tuition per child. Balance due by Dec. 31st.

The Himmelfarb School is eager to accommodate you and your children. We firmly believe that every child
should be able to receive a Jewish education, regardless of financial need. If any of these charges present a
concern to you, please contact David Zinner, Executive Director, at TIExec@tifereth-israel.org or by phone at
(202) 882-1605, ext. 103.
For additional information about our educational programs, contact Eitan Gutin, Director of Lifelong
Learning, at TILearning1@tifereth-israel.org or (202) 882-1605, ext. 105.
 Tifereth Israel Congregation
Himmelfarb Religious School
Assessment of Student Health 2010-11
This form will be kept in a confidential file in the office of the Director of Lifelong Learning. It will be shared with
your child’s teacher as necessary in order to provide the best possible experience for your child.

Student’s Name:_________________________________________ Grade:______________________

Does your child have any special condition(s) which may affect his/her learning, cause you a concern, and/or
might be important for school staff to know? Please answer by checking “yes” “no” or “don’t know” for each of
the following areas. If yes, PLEASE SPECIFY. Use the back of this page if needed. If any issues should arise
during the year, please notify us immediately.

Yes No Don’t Know

Allergies (e.g. insect stings, foods, drugs, pollens) ________ ________ ________
Specific physical condition/illness past or present ________ ________ ________
(e.g. cerebral palsy, epilepsy, diabetes, asthma)
Reading or perceptual issues (in particular, difficulty ________ ________ ________
in learning to read phonetically)
Hyperactivity or Attention Deficit Disorder ________ ________ ________
Hearing/Ear (e.g. frequent infections, draining ear, ________ ________ ________
hearing loss, hearing aid)
Vision/Eye (e.g. contact lenses, glasses, ________ ________ ________
uncorrectable condition)
Speech (e.g. delay, stammer, hard to understand) ________ ________ ________
Learning problems: in reading, writing, comprehension, ________ ________ ________
organization, speech/language, attention, memory, etc.

Does child have an IEP? (If so, please attach a copy) ________ ________ ________

General health (e.g. fatigue, low energy level, ________ ________ ________
frequent illness, sleep issues)
Behavior/personal relationships (e.g. very active, ________ ________ ________
needs to be center of attention, loner, easily upset,
shy, has difficulty making friends)
Identified as Gifted and Talented ________ ________ ________
Major changes or disruptions in your child’s life ________ ________ ________
I/We would like an appointment with the Director of ________ ________ ________
Lifelong Learning to discuss information related to this form.
Other information you would like to share with us:___________________________________________

___________________________________________________________________________________
 Himmelfarb Religious School Parent Volunteer Form 2010-11
Numerous studies indicate that the strongest school programs have involved parents and communities. With
your volunteer help we can provide the highest quality educational programming for your child(ren). Please take
a few moments to check the areas that interest you the most and return this form to the TI office. If you have
any questions, please contact Eitan Gutin, Director of Lifelong Learning, at 202-882-1605, ext. 105 or
TILearning1@tifereth-israel.org.

Tifereth Israel’s Life Long Learning Committee Volunteer possibilities:

___ Class Parent ___ Youth Groups ___ Shabbat Morning Committee

___ School Committee ___ Adult Ed. Committee ___ Early Childhood Committee

___ Curriculum Review Committee ___ Other _______________________________________

Times Potentially Available for Himmelfarb Volunteer Activities:

___ Sunday mornings 9:15am-12:15pm

___ Wednesdays 4:15pm-6:15pm
___ Wednesdays 6:15pm-8:15pm
___ Other times (please specify):________________________________________________

Areas for volunteer service in the Himmelfarb School (check all you are interested in):

___ Assisting in Main Office (greeting and/or assisting students and parents)

___ Site Supervision (sitting in lobby to monitor visitors during school hours)

___ Hebrew tutoring

___ Helping with small administrative tasks (such as copying)

___ Assisting in a classroom

___ Assisting in planning family programs

___ Helping with art projects or other special classroom projects

___ Sharing special interest with a class (cooking, Jewish history, Israeli dance, etc.).
Please specify:___________________________________________________________
___ Other. Please specify your interests and thoughts:_______________________________

Student Name(s):____________________________________________________________

Adult Name(s):______________________________________________________________
Phone Number(s):___________________________________________________________
Email(s):___________________________________________________________________
Best way and time to contact you: _______________________________________________

Todah Rabah!