Limmud Learning Registration

Limmud: Learning with Congregation Mishkan Or
Registration 2024-2025

Welcome! We are thankful you're here, and looking forward to engaging your family in our learning programs. Please note that our Pre-K class is open to the community, while all other grades are open to Congregation Mishkan Or members only.

If you have questions about any of the learning programs
please contact one of our co-Directors:
Staci Cohen, Dina Rock, Regina Krieger or call 216-831-3233

PARENT INFORMATION

Parent /Guardian 1 (please list the parent who will be the primary contact)

* First Name

* Last Name

* Email

* Cell Phone

Preferred Pronouns:

Pronouns:

Parent /Guardian 2

* First Name

* Last Name

* Email

* Cell Phone

Preferred Pronouns:

* Pronouns:

Unless indicated here both parents will have access to Limmud Learning records and information

Child/ren live/s with?

Child/ren reside with:

* Please share the name/s of spouses of Parent/Guardian 1 or 2

HOUSEHOLD INFORMATION

* Address

* Home Phone

* City

* State

* Zip Code

Sunday Limmud Learning Families - please choose a pick up option for your child/ren

TRIP, MEDICAL & EMERGENCY AUTHORIZATION

* Is Mishkan Or authorized to give your child/ren first aid?

* Does Mishkan Or have permission to include your name/address/phone number/email in distributed rosters to encourage Temple friendships?

* I give Congregation Mishkan Or permission to escort my child/ren within walking distance of the temple

* In the event reasonable attempts to contact me have been unsuccessful, I hereby give my consent for the administration of any treatment deemed necessary by a licensed physician or dentist and the transfer of my child to any hospital reasonably accessible. This authorization does not cover major surgery unless the medical opinions of two other licensed physicians or dentists, concurring in the necessity for such surgery, are obtained prior to the performance of such surgery.

By registering I give permission for my child/ren to be photographed with the picture to be used for temple marketing and promotions

I have read and agree with the above trip, medical and emergency authorization checked above. I agree to release Mishkan Or, its lay leaders and staff from any claim or loss arising out of my child(ren)'s participation in Limmud Learning. I have authority to sign this form on behalf of my family.

* Digital Signature:

Please type your full legal name in agreement with the above Trip, Medical & Emergency Authorizations.

Emergency Contacts (Other than Parent/Guardian 1 or 2)

* Emergency Contact #1 Name:

* Emergency Contact #1 Phone:

* Emergency Contact #1 Relationship

* Emergency Contact #2 Name

* Emergency Contact #2 Phone

* Emergency Contact #2 Relationship

CHILD 1

* First Name

* Last Name

* Nickname

* Hebrew Name

Preferred Pronouns:

* Please share prounouns:

* Birthdate

* Summer camp attended 2024

* Cell phone (if applicable)

* Email (if applicable)

* Name of School

* Name of School District

Please upload a recent picture of your child

* For which grade are you registering Child 1?

LIMMUD OPTION

* Please select your Limmud option

HEBREW OPTION

* Please select your Hebrew option

OTHER INFORMATION

* Please provide further details for any item checked above.

Please upload your child's IEP or 504 here

Are you registering a second child?

CHILD 2

* First Name

* Last Name

* Nick Name

* Hebrew Name

Preferred Pronouns:

* Please share pronouns

* Birthdate

* Summer camp attended 2024

* Cell phone (if applicable)

* Email (if applicable)

* Name of School

* Name of School District

* Please upload a recent picture of your child

For which grade are you registering Child 2?

LIMMUD OPTION

* Please select your Limmud option

HEBREW OPTION

* Please select your Hebrew option

OTHER INFORMATION

* Please provide further details for any item checked above.

Please upload your child's IEP or 504 here

* Are you registering a third child?

CHILD 3

* First Name

* Last Name

* Nick Name

* Hebrew Name

Preferred Pronouns:

Please share prounouns:

Birthdate

* Summer camp attended 2024

* Cell phone (if applicable)

* Email (if applicable)

* Name of School

* Name of School District

Please upload a recent picture of your child

* For which grade are you registering Child 3?

LIMMUD OPTION

* Please select your Limmud option

HEBREW OPTION

* Please select your Hebrew option

OTHER INFORMATION

* Please provide further details for any item checked above.

Please upload your child's IEP or 504 here

* Are you registering a fourth child?

CHILD 4

* First Name

* Last Name

* Nick Name

* Hebrew Name

Preferred Pronouns:

* Please share prounouns:

* Birthdate

* Summer camp attended 2024

* Cell phone (if applicable)

* Email (if applicable)

* Name of School

* Name of School District

Please upload a recent picture of your child

* For which grade are you registering Child 4?

LIMMUD OPTION

* Please select your Limmud option

HEBREW OPTION

* Please select your Hebrew option

OTHER INFORMATION

* Please provide further details for any item checked above.

Please upload your child's IEP or 504 here

Total:

Congregation Mishkan Or. We're Stronger Together.