JEWISHLEARNINGREIMAGINED ATID REGISTRATION Bar/Bat Mitzvah learning re-imagined. An innovative program for students in grades 5-8. Step 1 of 3 33% Your Name* First Last Your Email* Registration InformationHow did you first hear about Makom ATID?*Word of mouth (friend or relative)FacebookMakom Afterschool's websiteMakom websiteMakom NewsletterMakom Afterschool newsletterHow many children are you registering?*One childTwo childrenFor which days are you registering your child(ren)?*All students must attend the required Jewish Learning day (most likely Wednesdays). The Hebrew learning day (most likely Mondays) will be optional. Please consult with Rabbis Emma or Aaron before opting out of the Hebrew learning day. Hebrew proficiency is required for those who wish to have a Bar/Bat Mitzvah ceremony that includes Torah reading. Jewish Learning Day (likely Wednesdays, 4:15-5:45) Optional Hebrew Learning Day (likely Mondays, 4:15-5:45) Child Name* First Last Birthdate* To help us determine the correct Hebrew birthday for your child please indicate if they were born:Before sunsetAfter sunsetHebrew Name (if known)Grade in September 2017*Grade 5Grade 6Grade 7Grade 8Gender*MaleFemaleWhat school will your child attend during regular school hours?*As of September 2017Would you like us to put you in touch with other parents who are sending their children to ATID from the same school or neighbourhood as you?YesNoIf you are registering for the Hebrew Learning Day, please indicate child's level of Hebrew learning:Beginner = Little to no Hebrew learning / cannot read Hebrew; Intermediate = Can read Hebrew but not understand it; Advanced = can read Hebrew and understands some HebrewBeginnerIntermediateAdvancedApproximately when would you like your child to have a Bar/Bat Mitzvah ceremony?*Please give an approximate month/year. Medical InformationChild's Doctor*Doctor's Phone Number*Does your child have any significant medical conditions, physical limitations, or any other concerns that might affect her/his full participation in program activities or require any modification of her/his participation?*YesNoIf yes, please describe and provide details of usual treatment:Does your child wear or carry medical alert identification?*YesNoIf yes, please specify what is written on it:Does your child take prescribed medication on a regular basis?*YesNoIf yes, please specify:Allergies/AsthmaDoes your child have any allergies?*YesNoPlease list all known allergies to foods, medications, or other allergens (e.g., bee or wasp stings, environmental allergies):Is the allergy considered:MildModerateSeriousLife-ThreateningPlease explain symptoms and treatment:Has your child ever suffered a serious allergic or asthmatic reaction?*YesNoPlease provide details, including the type and severity of reaction:Has a doctor prescribed an Epi-Pen for your child?*Prescribed epi-pens must be carried by the student at all times.YesNoHas a doctor prescribed an inhaler for asthma?*Prescribed asthma inhalers must be carried by the student at all times.YesNoHas a doctor prescribed an inhaler for any other reason?*YesNoIf yes, please provide details:Dietary RestrictionsPlease list any foods your child should not eat for medical, dietary, or religious reasons:Please include any food allergies that were listed previously in the allergy section.Individual ConsiderationsWe recognize that all children learn and socialize differently. Makom ATID is inclusive and aims to provide as much individualized support as we can. To that end, the more information you can share with us about your child, the better able we will be to accommodate and support their individual needs. This information will be kept in confidence and will only be shared with the program director and your child's teachers.Please tell us about your child’s learning and communication styles, including strengths and challenges.This might include identified learning disabilities, autism spectrum, and giftedness.Does your child have an Independent Educational Plan? If yes, please email a copy of it to familyed@makomTO.org.*YesNoPlease share any strategies or accommodations that are used for your child at school or at home, that may be useful for us to consider at Makom ATID.Does your child have any physical challenges or limitations that require support or accommodation?If so, please describe in detailFamily LifeWe know that situations within the home and family affect children at school and in social settings. Please share with us if there are any situations or recent events in your family that we should be aware of (e.g. recent deaths or marital changes).Please share any additional information about your child that we might need to know. Second Child - Name First Last Birthdate* To help us determine the correct Hebrew birthday for your child please indicate if they were born:Before sunsetAfter sunsetHebrew Name (if known)Grade in September 2017*Grade 5Grade 6Grade 7Grade 8Gender*MaleFemaleWhat school will your child attend during regular school hours?*As of September 2017Would you like us to put you in touch with other parents who are sending their children to ATID from the same school or neighbourhood as you?YesNoIf you are registering for the Hebrew Learning Day, please indicate your child's level of Hebrew learning:Beginner = Little to no Hebrew learning / cannot read Hebrew Intermediate = Can read Hebrew but not understand it Advanced = can read Hebrew and understands some HebrewBeginnerIntermediateAdvancedApproximately when would you like your child to have a Bar/Bat Mitzvah ceremony?*Please give an approximate month and yearMedical InformationChild's Doctor*Doctor's Phone Number*Does your child have any significant medical conditions, physical limitations, or any other concerns that might affect her/his full participation in program activities or require any modification of her/his participation?*YesNoIf yes, please describe and provide details of usual treatment:Does your child wear or carry medical alert identification?*YesNoIf yes, please specify what is written on it:Does your child take prescribed medication on a regular basis?*YesNoIf yes, please specify:Allergies/AsthmaDoes your child have any allergies?*YesNoPlease list all known allergies to foods, medications, or other allergens (e.g., bee or wasp stings, environmental allergies):Is the allergy considered:MildModerateSeriousLife-ThreateningPlease explain symptoms and treatment:Has your child ever suffered a serious allergic or asthmatic reaction?*YesNoPlease provide details, including the type and severity of reaction:Has a doctor prescribed an Epi-Pen for your child?*Prescribed epi-pens must be carried by the student at all times.YesNoHas a doctor prescribed an inhaler for asthma?*Prescribed asthma inhalers must be carried by the student at all times.YesNoHas a doctor prescribed an inhaler for any other reason?*YesNoIf yes, please provide details:Dietary RestrictionsPlease list any foods your child should not eat for medical, dietary, or religious reasons:Please include any food allergies that were listed previously in the allergy section.Individual ConsiderationsWe recognize that all children learn and socialize differently. Makom ATID is inclusive and aims to provide as much individualized support as we can. To that end, the more information you can share with us about your child, the better able we will be to accommodate and support their individual needs. This information will be kept in confidence and will only be shared with the program director and your child's teachers.Please tell us about your child’s learning and communication styles, including strengths and challenges.This might include identified learning disabilities, autism spectrum, and giftedness.Does your child have an Independent Educational Plan? If yes, please email a copy of it to familyed@makomTO.org.*YesNoPlease share any strategies or accommodations that are used for your child at school or at home, that may be useful for us to consider at Makom ATID.Does your child have any physical challenges or limitations that require support or accommodation?If so, please describe in detailFamily LifeWe know that situations within the home and family affect children at school and in social settings. Please share with us if there are any situations or recent events in your family that we should be aware of (e.g. recent deaths or marital changes).Please share any additional information about your child that we might need to know. Parent/Guardian 1 - Name* First Last Parent/Guardian 1 - Email* Parent/Guardian 1 - Home Phone*Parent/Guardian 1 - Cell Phone*Parent/Guardian 1 - Work PhoneParent/Guardian 1 - Address* Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland & LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Second Parent/Guardian InformationParent/Guardian 2 - Name First Last Parent/Guardian 2 - Email Parent/Guardian 2 - Home PhoneParent/Guardian 2 - Cell PhoneParent/Guardian 2 - Work PhoneParent/Guardian 2 - Address Same as Parent/Guardian 1 Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland & LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code With whom does your child (/children) live?*Please contact our director at familyed@makomto.org if there is anything you need us to know about your family situation or your child's guardianship.Parent/Guardian 1Parent/Guardian 2Both Parents/GuardiansAdditional Family InformationPlease answer the following questions to help us better understand the makeup of our Makom Afterschool communityIs anyone in the child's immediate family a member of a local synagogue?*Yes (one parent/guardian)Yes (both parents/guardians)NoIf yes, please share the name of the synagogue?Do you attend High Holiday services at a synagogue?*YesNoIf yes, where do you attend?Is anyone in the child's immediate family a member of a local JCC?*Yes, one or both parents/guardians (MNJCC)Yes, one or both parents/guardians (a different JCC)No, neither parent/guardian is a memberDo you participate in Makom programs aside from Makom ATID?*Yes, we doNo, and we're not interestedNo, and we'd like more informationDo you see Makom as your primary Jewish community or one of your Jewish communities?*Yes (it is our primary Jewish community)Yes (it is one of our Jewish communities)No, it is notParent/Guardian 1: How would you describe your current Jewish identity?*Please select all that apply Conservative Culturally Jewish Israeli Just Jewish Orthodox Post-Denominational Queer Jewish Reconstructionist Reform Secular Sephardi/Mizrahi Not Jewish but married/partner to a Jew Other If other, please specifyParent/Guardian 2: How would you describe your current Jewish identity?Please select all that apply Conservative Culturally Jewish Israeli Just Jewish Orthodox Post-Denominational Queer Jewish Reconstructionist Reform Secular Sephardi/Mizrahi Not Jewish but married/partner to a Jew Other If other, please specifyEmergency/Pick-up InformationEmergency Contacts (aside from parents/guardians listed above)*NameCell PhoneRelationship to child Authorized Persons for Pick-UpThe following individuals, in addition to the above listed parent(s), are authorized to drop off or pick up my child from Makom Afterschool:NameCellRelationship to child Permissions & WaiversThe following permissions and waivers are required for enrollment in Makom ATID. If you have any questions or concerns, please contact familyed@makomto.orgWaiver*I hereby release Makom, their staff, contractors and volunteers from all claims, demands, losses, suits, or proceedings resulting from the participation of my child in any facility or at any location where a program is being held.AgreeTrip Permission*I give permission for my child to participate in Makom field trips. I understand that transportation will be either by carpool, school bus, TTC, or by foot, as appropriate.AgreePhoto/Video Release*I give permission to Makom to photograph or videotape my child during program hours or at any program-related activity, and to use such photographs in program communications or publicity of any kind, including but not limited to newsletters, event flyers and on Makom’s website and social media such as Facebook. I understand that my permission means that Makom is best able to publicize Makom Afterschool to potential students and others. Permission does not include use of my child’s photograph for any purpose other than to communicate information about Makom. I understand that my child’s name will not be published unless I am explicitly asked for additional consent.AgreeI would prefer to sign an opt-out formParent Contact List*I give permission for my email and phone number to be shared with other Makom ATID parents.AgreeTuition Deposit Amount Due*Annual tuition for Jewish Learning Day only: $1650. Annual tuition for Jewish Learning + Optional Hebrew Learning: $2250. Tuition deposit is 20% of total tuition.Jewish Learning Day OnlyJewish Learning & Hebrew LearningNumber of children registering*12Total Deposit DueThis is the total amount due to confirm your registration. $ 0.00 CAD How would you like to pay your deposit?*You can pay your deposit by e-transfer or through PayPal (credit card payments can be made through PayPal).PaypaleTransferNameThis field is for validation purposes and should be left unchanged. 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