Registration for Community Members 2025-2026 Youth and Family Programs - Form

A Message from the Youth and Family Education Department

Shalom! Thank you for choosing BZBI for your children's After School Jewish Education this year!

We are excited that you and your child(ren) are a part of the Youth and Family Education community at BZBI! This form is specifically for those who are not yet BZBI members and would like to register their children for our Wednesday and/or Saturday Youth Programming.

If you would like information about BZBI Membership or if you have any questions about Education at BZBI for any age, please feel free to reach out to Stacey Lasky, Director of Congregational Learning.

We are looking forward to an exciting and rewarding year of learning with your children!

L’Shalom,

Stacey

Before completing the form, please note the following:

- Progress cannot be saved, so please leave enough time to complete and submit the
entire form.

- Payment information is due upon completion of this form. The form cannot be
successfully submitted without payment information.

- Payment options: If you are logged into your ShulCloud account you can...
(1) Pay by credit card online (there is a 3.0% credit card fee)
(2) Pay by debit card online (no service fee)
(3) Pay by e-check online (there is a 1.5% fee to pay by e-check)
(4) Checks are always welcome.

Parent / Guardian Information

* First Name of Primary Guardian

* Last Name of Primary Guardian

If there is more than one parent/guardian in your household, please make this first contact the adult who will serve as the primary point of contact should the synagogue need to reach you. Up to three additional points of contact can be added.

* Street Address (Line 1)

Street Address, Line 2

* City

* State

* ZIP Code

* Email Address

* Mobile Phone

Do you want to add a second parent / guardian?

YesNo

* First Name

* Last Name

* Street Address (Line 1)

Street Address, Line 2

* City

* State

* ZIP Code

* Email Address

* Mobile Phone

Are there custody or payment arrangements BZBI needs to be aware of?

YesNo

Please explain

Are you a member of another synagogue?

YesNo

Which synagogue are you a member of?

* EMERGENCY MEDICAL CARE AUTHORIZATION: BZBI will immediately notify the parents, guardians, or Emergemcy Contact in the event of a medical emergency. If these people are unable to be reached, I authorize BZBI staff to perform First-Aid, contact 911, and allow my child to be transported by First Responders to a hospital..

EMERGENCY MEDICAL CARE AUTHORIZATION: BZBI will immediately notify the parents, guardians, or Emergemcy Contact in the event of a medical emergency. If these people are unable to be reached, I authorize BZBI staff to perform First-Aid, contact 911, and allow my child to be transported by First Responders to a hospital..

Registration Information

First Child's Information
Additional children can be registered later in this form

* Child's First Name

* Child's Last Name

* Prefered Pronouns

* Date of Birth

* Name of Secular or Jewish Day School

* Grade (2025-2026 school year)

* What would you like us to know about your child to best help them succeed?

REGISTRATION SELECTION

Monday Neziner Ulpan for 3rd-7th Graders (4:30-5:30) and Wednesday Neziner Garinim ($2250)Wednesday Neziner After School Hebrew Program (PreK-7th Grade) ($1550)Wednesday PreCare Supplement: School PickUp, Chaperoned Walk, Snack, and Supervision ($150)Shabbat No'ar (Saturday Youth Program) and Bonim (PreK/Kindergarten) ($360)

CONFIDENTIAL HEALTH INFORMATION

Does your child have any allergies? Please list allergies:

Please list any health, learning, or other needs of which we need to be aware, including if there is an IEP, 504, or if your child is under regular care of a physical or mental health professional.

Please help us to best support your child.

Would you like to register another child?

YesNo

ADDITIONAL PREK-7TH GRADER REGISTRATION

Second Child's Information
Additional children can be registered later in this form

* Child's First Name

Child's Last Name

* Prefered Pronouns

* Date of Birth

* Name of Secular or Jewish Day School

* Grade (2025-2026 school year)

What would you like us to know about your child to best help them succeed?

REGISTRATION SELECTION

CONFIDENTIAL HEALTH INFORMATION

Does your child have any allergies? Please list them.

Please list any health, learning, or other needs of which we need to need to be aware, including if there is an IEP, 504, or if your child is under regular care of a physical or mental health professional.

Please help us to best support your child.

ADDITIONAL PREK-7TH GRADER REGISTRATION

Would you like to register another child?

YesNo

Third Child's Information

* Child's First Name

* Child's Last Name

* Prefered Pronouns

* Date of Birth

* Name of Secular or Jewish Day School

* Grade (2025-2026 school year)

What would you like us to know about your child to best help them succeed?

REGISTRATION SELECTION

CONFIDENTIAL HEALTH INFORMATION

Does your child have any allergies? Please list all allergies.

Please help us to best support your child.

EMERGENCY CONTACTS & ADDITIONAL AUTHORIZED ADULTS

* Emergency Contact (Other than Parent/Guardian Already Listed) This person may also be authorized to pick up children from Youth and Family activities)

* Relationship

* Mobile Phone

* Names of those (other than parents/guardians) authorized to pick up children from Youth & Family Activities:

PAYMENT

Payment information is due upon completion of this form. The form cannot be
successfully submitted without payment information.

- Payment options: If you are logged into your ShulCloud account you can...
(1) Pay by credit card online (there is a 3.0% credit card fee)
(2) Pay by debit card online (no service fee)
(3) Pay by e-check online (there is a 1.5% fee to pay by e-check)
(4) Checks are always welcome.

Please consider making a tax-deductible donation towards our Youth & Family Shabbat Programming.

* I confirm that all the information provided in this form is true, and I understand that by signing it I acknowledge and agree to all the above statements.

I confirm that all the information provided in this form is true, and I understand that by signing it I acknowledge and agree to all the above statements.

* Please type your name here to indicate agreement

Total Due

If you have any questions about the registration form, please contact Stacey Lasky, Director of Congregational Learning.