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BJP Registration

For more information, contact the Beth Jacob Preschool office at BJPreschool@BethJacobAtlanta.Org

*Please note our Pre-K, One year old, 18 month and 3 year old classes, and Infant Room are now CLOSED*

We are only accepting applications for our 2 year old classes

*We will no longer be accepting applications for the classes listed above*

* After Care is now FULL. We are no longer accepting children for After Care*

Please fill out this registration form COMPLETELY. Review before submitting this form. Thank you

(one per child)

* Receipt Email

Child’s Legal Name

Birthdate

Sex

Hebrew Name

Nickname:

Street Address:

City

Zip Code

Home Phone

Mother's Name

Mother's Cell Phone

Mother’s Occupation:

Mother’s Work Phone:

Mother’s Work Address:

Mother’s Email Address:

Jewish from birth?

YesConversion

Mother’s Street Address (if different from the child’s):

City

State

Zip Code:

Father’s Name:

Father’s Cell Phone:

Father’s Occupation:

Father’s Work Phone:

Father’s Email Address:

Jewish from birth?

YesConversion

Father’s Street Address (if different from the child’s):

City

State

Zip

Child’s Living Arrangements (check one):

Both ParentsMotherFatherOther

Child’s Legal Guardian/s (check one):

Both ParentsMotherFatherOther

Does your child keep Cholov Yisroel:

YesNo

EMERGENCY & MEDICAL CONTACT INFORMATION
In the event of illness, injury or an emergency where the parents cannot be reached, the following people can be contacted:

Name:

Relationship to Child:

Home Number:

Cell Number:

Work Number:

Home Address:

Name:

Relationship to Child:

Home Number:

Cell Number:

Work Number:

Home Address:

Physician/Clinic:

Phone:

Insurance Information (in case of emergency)

MEDICAL INFORMATION

Is there any medical/family/physical/special need information you think we should know about your child?

My child has received evaluation or therapy from the following services:

Developmental PediatricianOTPTSpeechPsychologistHearingVision

How can Beth Jacob Preschool best address your child’s needs?

MEDICAL EMERGENCY TREATMENT AUTHORIZATION

I understand that every effort will be made to contact me in the event of an emergency requiring medical attention for my child. However, in the event of an emergency requiring medical attention for my child, and if I cannot be reached, or when delay would be dangerous to my child’s health, I hereby authorize Beth Jacob Preschool to transport my child to the nearest medical facility and/or hospital. I hereby authorize Beth Jacob Preschool to secure for my child the necessary medical treatment. I shall assume responsibility for payment for services.

Please initial above.

ON-GOING MEDICATIONS

My child is currently taking on-going medication(s) and has the following pre-existing illness, allergies, or health concerns:

This medication must be administered during Preschool hours

YesNo

If yes, please describe the dosage and specific instructions (with/out food etc.):

* Please initial here.

ALLERGIES

YesNo

If yes, please check all that apply

Tree nuts (walnuts, almonds, pecans, etc.)Fish/shellfishEggsPeanut or nut butterSoy productsMilksPlantsAnimalsInsectsMedicineAsthmaHay Fever

Other Allergies?

Please describe the allergic reaction and the treatment for each allergy checked:

* PARENTAL AUTHORIZATION TO DISPENSE EXTERNAL PREPARATIONS 590-1-1-.20(1)

Except for first aid, personnel shall not dispense prescription or non-prescription medications to a child without specific written authorization from the child's physician or parent. When applicable, please request an authorization form from the office, or access the authorization form online which will include: date, full name of the child, name of the medication, prescription number, dosage (dates and times) while in school and signature of parent.

Please initial above.

NON-EMERGENCY MEDICATION

Baby WipesBand-aidsNeosporin or similar ointmentBactine or similar first aid spraySunscreenInsect RepellentNon-Prescription ointment (such as A & D, Desitin, Vaseline)

I give Beth Jacob Preschool permission to apply one or more of the following topical ointments/preparations to my child in accordance with the directions on the label of the container (initial next box)

* NON-EMERGENCY MEDICATION

Please initial here.

Other Non Emergency Medication (please specify)

ADDITIONAL CHILD INFORMATION

Pet’s name(s) and animal types

Please tell us about your child. Include his/her personality, temperament, eating habits, etc

CARPOOL PICK UP INFORMATION

Please list any family members, nannies, babysitters or friends that may be picking your child up from school.

Name

Cell Phone:

Name:

Cell Phone:

_____ Please initial here.

PARENT AGREEMENT WITH BETH JACOB PRESCHOOL

* Please initial below

I understand that Beth Jacob Preschool is run under Bright from the Start licensing.

* Please initial below

According to Bright from the Start, our state licensing agency, we must have signed parental agreement for mixed age classrooms. Therefore, I agree for my child to be in the same classroom as other children of different ages, for example in the case of early morning drop off or after care.

I give my permission for taking my child’s photograph/video that might be used on Beth Jacob’s website page and/or publicity materials.

YesNo

* Please initial below (re: photography/video)

I give permission for my address, phone number and email to be released to other Beth Jacob Preschool families. This is used primarily for a Preschool Directory as well as to give to parents for birthday party invitations.

YesNo

* Please initial below (re: sharing information)

* Initial Above

I understand that before my child starts school that I must provide (or give access to) up-to-date immunization records. (Note: Beth Jacob Preschool has legal and confidential access to all child immunization records.) YOUR CHILD MUST HAVE CURRENT IMMUNIZATIONS TO ATTEND BETH JACOB PRESCHOOL ON THE FIRST DAY THAT HE/SHE WILL ATTEND BETH JACOB PRESCHOOL. BETH JACOB PRESCHOOL CAN ACCESS YOUR CHILD’S CURRENT CERTIFICATE OF IMMUNIZATIONS from the Georgia Department of Public Health (form 3231).

* Initial Above

I acknowledge it is my responsibility to keep my child's records current to reflect any significant changes as they occur, e.g., telephone numbers, work location, emergency contacts, child's physician, child's health status, infant feeding plans, carpool retrievers and immunization records, etc

Beth Jacob Member

YesNo

Synagogue Affiliation

If you are not a member, may a Beth Jacob representative contact you about possible membership?

YesNo

My child will attend BJ Preschool during these hours: (check all that apply)

You MUST fill out your child’s schedule below in order for your application to be processed

Half Day (8:45am-1:00pm)

All 5 DaysMondayTuesdayWednesdayThursdayFriday

Full Day (8:45am-3:00pm)

All 5 DaysMondayTuesdayWednesdayThursdayFriday

After Care until 4

All 4 DaysMondayTuesdayWednesdayThursday*we will not have After Care on Fridays

Total Yearly Tuition for this child:

I wish to use FACTS to pay for Tuition; Automatic Withdrawal ONLY

Please charge to my FACTS account.I do not have a FACTS account but would like to open one.

Full payment via has been mailed and made out to Beth Jacob Preschool. If paying in full now via check, please put check number above.

TUITION AND POLICY AGREEMENT

Parent Name

Child Name

* Signature

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Date

Enter Preschool Tuition Payment Amount (before scholarship):

* Initial Below

FINANCIAL OBLIGATIONS: Enrollment is confirmed after receipt of completed application AND the non-refundable application fee ($200 until February 14, after February 14 $300) and financial agreements has been completed.

Application Fee

$200 (until February 14)$300 (after February 14)

* Initial Below

MEMBER RATE: Tuition will be charged at the member rate for families who maintain full membership status and are current in their Beth Jacob dues as of June 2023 when billing for the year is established. Annual financial obligations to Beth Jacob must be kept current throughout the school year. Families who become Beth Jacob members after the start of the school year will receive the member tuition rate for the remainder of their tuition once their first dues payment has been submitted. Members who do not remain in good standing, as determined by Congregation Beth Jacob, are at risk for their tuition reverting to the non-member rate.

* Initial Below

WAIVER: For themselves, their agents and their children, parents, by entering their signatures below on this form, waive any and all claims of every nature and description they, their agents or their children may have in the future against Congregation Beth Jacob Preschool, its administrators, teachers, employees or agents related to the Preschool unless such claims arise from the intentional wrongful acts or gross negligence of those parties otherwise released.

* Parent/Guardian Signature and Date

By signing above, you commit to paying the full year’s tuition as indicated by your program selection(s) on this application (except in the case of relocation away from the Atlanta metro area). Per Rabbi Ilan D. Feldman, your signature below enters you into a halachically binding contract with the synagogue. The synagogue will enforce this responsibility fully.

All previous made financial arrangements with Beth Jacob Preschool are null and void. If you need to apply for financial assistance, please fill out the Application for Scholarship located at the end of this registration form.

By signing this document, I agree to have my child up-to-date with his/her immunizations before the first day of school.

I hereby register my child as a student of Congregation Beth Jacob Preschool and agree to abide by all school rules and regulations, as outlined in the Beth Jacob Preschool Handbook.

Application for Scholarship
If you are seeking a scholarship for tuition at Beth Jacob Preschool, please follow these directions carefully. You MUST

submit an application with the Registration fee BEFORE your Scholarship will be considered.

Please know that each scholarship application will be kept in complete confidence. We will be utilizing FACTS to assist us in determining eligibility for scholarship. Even if you do not choose to use FACTS as your payment for tuition, we will still need you to complete ALL the information in FACTS to help us best assess your financial aid.

Steps in applying for scholarship:

Sign into FACTS. Follow all instructions from FACTS to apply for grant/aid. Use this link to help you sign up: https://online.factsmgt.com/ga/aid/inst/3GDKH. Their customer service phone number is 866-441-4637.
Please check your FACTS account regularly to make sure that all the required information has been submitted and completed.
Once all your information has been submitted in FACTS and your registration has been submitted along with your $200/$300 registration fee to the Preschool office, your application for scholarship will be reviewed by our BJ Preschool Scholarship Committee.
All fully completed applications for scholarship must be received by 5pm, March 31, 2023. No additional scholarships will be awarded after that date for the 2023-2024 school year.

Child’s Legal Name

Birthdate

Mother’s Name:

Mother’s Cell Phone:

Mother’s Work Phone:

Mother’s Email Address:

Father’s Name:

Father’s Cell Phone:

Father’s Work Phone:

Father’s Email Address:

* Please make sure all three boxes are checked before submitting this form.

I have completed all the necessary forms through FACTS.I have completed my application in full.I have sent in a non-refundable registration fee which will be applied to my tuition.

* Name and Date

DISCLAIMER: By typing your name above, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

By signing in the signature block above, as well as in every other signature and initial block within this document, I hereby confirm that it is my intention to be legally bound by all of the obligations, terms, and conditions contained within this document.

Sat, April 20 2024 12 Nisan 5784