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Chavaya Registration Grades K-6th 2021-2022

Chavaya is Temple Israel of New Rochelle's Religious School program for Kindergarten - 12th Graders.

Applications must be completed in one computer session using a desktop computer or laptop. This application is not "user friendly" with PDA devices, so please use a computer to complete the application.

Complete one application per child. Full payment or first installment of a payment plan is required in order to complete the application. Registrations must be completed on or before Friday, August 6th.

Contact the Chavaya Office at chavaya@tinr.org with questions.

Information About Child

* Name of Child (Last, First)

* New or Returning?

New Participant
Returning Participant

Nickname

* Birthdate (MM/DD/YYYY)

* Gender child associates with

Male
Female
Non-Binary

Child's Hebrew Name

* Primary Address of Child (Address, City, State, Zip)

* Home Phone Number (###-###-####)

Child's Cell Phone for Programming Purposes Ahleem (5th & 6th Grade) and Up (###-###-####). If not applicable, please note n/a.

Child's Email Address for Programming Purposes Ahleem (5th & 6thth Grade) and Up. If not applicable, please note n/a.

* Child's Secular School as of September 2021

* Child's Secular Grade as of September 2021

* Please list a maximum of three participants with whom your child would like to be in a group. (We will do our best to factor these requests in with other considerations such as group size, gender balance and group dynamics.)

Chavaya Tuition is subsidized by Temple Israel. Please consider paying the actual cost of tuition for the Temple. The difference is a tax deductible donation.

A 3% administrative fee will be added if you choose to pay by credit card.

In registering my child in the Chavaya program, I am making the financial commitment for the year. I understand that tuition is non-refundable after Thursday, October 28th. If I select a payment plan option, I am still responsible for the remaining balance due.

Please click that you understand that tuition is non-refundable after Thursday, October 28th.

Registration Options-You must select ONE of the four following options

1. I would like to pay in full at this time, the Actual Cost of Chavaya to Temple Israel.

2. I would like to pay in full at this time, the Chavaya Tuition to Temple Israel.

3. I would like to pay the Actual Cost over a 9 month period.

4. I would like to pay the Chavaya Tuition over a 9 month period.

Parent Information

* Name of Parent/Guardian 1 (Last, First)

* Parent/Guardian 1 Home Phone Number (###-###-####)

* Parent/Guardian 1 Home Address (Address, City, State, Zip)

* Parent/Guardian 1 Cell Phone Number (###-###-####)

Parent/Guardian 1 Work Number (###-###-####)

* Parent/Guardian 1 Email Address

Name of Parent/Guardian 2 (Last, First)

Parent/Guardian 2 Home Address (Address, City, State, Zip)

Parent/Guardian 2 Home Phone Number (###-###-####)

Parent/Guardian 2 Cell Phone Number (###-###-####)

Parent/Guardian 2 Work Number (###-###-####)

Parent/Guardian 2 Email Address

Name of Parent/Guardian 3 (Last, First)

Parent/Guardian 3 Home Address (Address, City, State, Zip)

Parent/Guardian 3 Home Phone Number (###-###-####)

Parent/Guardian 3 Cell Phone Number (###-###-####)

Parent/Guardian 3 Work Phone Number (###-###-####)

Parent/Guardian 3 Email Address

Education & Youth Committees

I am interested in learning more about the committees that support education and youth group programs.

Emergency Contact Information if we can't reach a Parent or Guardian

* Name of Emergency Contact 1 (Last, First)

* Emergency Contact 1 Home Phone Number (###-###-####)

* Emergency Contact 1 Cell Phone Number (###-###-####)

* Emergency Contact 1 Relationship to Child

Name of Emergency Contact 2 (Last, First)

Emergency Contact 2 Home Phone Number (###-###-####)

Emergency Contact 2 Cell Phone Number (###-###-####)

Emergency Contact 2 Relationship to Child

Medical/Learning Information

Please provide any information, such as medical needs, which may be of help to the Chavaya Director and faculty.

Please include information if your child has an IEP or 504 in place in their secular school as this information may be helpful in addressing their specific needs. This information will be kept confidential by the Chavaya Director, and will only be shared with the Faculty and Clergy as needed.

Medications that your child takes on a regular basis, and will need to use during Chavaya hours:

Allergies (especially food allergies). Please be specific.

If your child has food allergies and will need to keep an Epi-Pen in the office click here.

Yes

If your child uses an inhaler for asthma, and will need to keep one in the Chavaya office click here.

Yes

Does your child have any medical exemptions that would prevent them from being able to wear a mask? Please note that we will be looking for guidance from the CDC in addition to our local district's policy about mask wearing in the fall.

	Yes, my child has a medical exemption.
	No, my child does not have a medical exemption, and will wear a mask while participating in Chavaya programming.

If you answered "Yes" to the question above, please describe your child's medical exemption.

* Has your child received the COVID vaccine? Please note that we expect that eligibility will increase as the CDC makes it available to children.

	Yes, my child has received the COVID vaccine.
	No, my child has not received the COVID vaccine.
	No, my child has not received the COVID vaccine but we plan to have them vaccinated once they become eligible.

* Physician's Name (Last, First)

* Physician's Phone Number (###-###-###)

* Name of Insurance Company

* Insurance Company ID

* Policy #

* Insurance Company Phone Number (###-###-####)

Immunization Record & Community Brit (Behavior Contract)

* All registered children must submit an up-to-date immunization record and the Chavaya Brit (behavior contract) in order to participate in programming.

I understand that we will need to sign and return these documents for registration to be complete.

Authorizations

The child listed above has my permission to engage in all Temple Israel of New Rochelle (TINR) Chavaya Programming and Youth Group activities except as noted below.

In the event that I cannot be reached in an emergency, I hereby give permission to TINR to seek emergency medical treatment and arrange necessary related transportation for my child. I hereby give permission to the physician/health care provider selected by TINR to secure and administer treatment, including hospitalization, for the person named above.

When a TINR event is not on the temple premises, I give permission for my son/daughter to be driven to and from the event by an authorized mode of transportation. I agree to indemnify and hold harmless TINR, their employees, volunteers, and members from any harm which may come to my son/daughter while in transport to or from the event, or during said event.

* I am aware that pictures of my child may be taken at TINR events and give permission for them to be posted on the TINR website or printed in TINR publications.

Exceptions for Child

* By checking this box I agree to the above authorization and that the responses are as accurate as possible.

Children in 5th & 6th grade: Temple Basketball Program

Yes, I am interested in learning more about the temple basketball program.

Contact Basketball Commissioner Jeff Berenbaum at jberenbaum@optonline.net for more information.

Please make sure the registration form is completed in its entirety and click "register."

Donation to Chavaya

We greatly appreciate your contribution to help defray the costs of our program. Donations are tax deductible.

Account Details

Enter your name and e-mail address for your confirmation:

*E-mail

*First Name

*Last Name

Payment Information

Account

Online Fee:

Credit Card

Name on Card

Card Type

Card Number

Expiration Date

Card Verification Number

Address Line 1

City

State/Province

Zip

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