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STUDENT/CAMPER APPLICATION FORM

Child's Information

*Last Name

*First Name

*Hebrew Name

*Date of Birth

*Address

*City

*Postal Code

*Home Telephone

Is there any special information we should know about your child? (If yes, please elaborate.)


Father's Information

*Name

*Cell Phone

*E-mail Address

Occupation

Company Name

Company Address

Company Phone

*Is father's home address the same as child's (address above)? Yes   No

If no, please provide address below: 

    


Mother's Information

*Name

*Hebrew Name

*Cell Phone

*E-mail Address

Occupation

Company Name

Company Address

Company Phone

*Is mother's home address the same as child's (address above)? Yes   No

If no, please provide address below:

 


Program Attending

PRESCHOOL (8:15-3:00, closed for breaks)
5 Mornings (Pre-Nursery & Nursery): Mon-Fri, 9:00 am-12:00 pm
5 Extended Days (Pre-Nursery, Nursery & JK): Mon-Fri, 9:00 am-3:00 pm with lunch

DAYCARE (8:15-5:00, open during breaks)
5 Full Days (all ages, including infants): Mon-Fri, 8:15 am-5:00 pm with lunch (Fri: Early closing for Shabbat during Fall/Winter)

Which session will your child be attending?
Camp (July-Aug 2022)     Pre-School/Daycare (Sept 2022-June 2023)     Both Camp & School (July 2022-June 2023)

If your child will have different schedules for camp and school (i.e. different days or hours), please write what you would like for each below:



*My child will start in the month of ,
in the year

Have there been any conversions in the family? Yes   No

If yes, please elaborate



Was this child born to a Jewish mother? Yes   No

Are you a member of a Synagogue? Yes   No

If yes, which one?

 

Medical Information

*Pediatrician Name

*Pediatrician Telephone

*Pediatrician Address

Allergies or Medical Conditions:

  

*Does your child have any communicable diseases?  Yes   No

If yes, please elaborate  

In case of emergency, contact (other than parent)

Emergency Contact #1

*Name

*Address

*Relationship to Child

*Telephone

Cell

Emergency Contact #2

*Name

*Address

*Relationship to Child

*Telephone

Cell

Permission to Receive Emergency Care
I hereby grant permission to Gan Shalom Preschool to take whatever steps are necessary to
obtain emergency medical care if warranted. These steps may include but are not limited to the following:
1. Attempt to contact parent.
2. Attempt to contact child’s physician.
3. Attempt to contact emergency contact person.

If we cannot contact the above, we will do all or any of the following:
1. Call another physician.
2. Call an ambulance.
3. Have the child taken to the nearest emergency room at a hospital by a staff member.

Any expenses incurred under the circumstances will be borne by the child’s family.

Gan Shalom will not be responsible for any incident that may occur as a result of false information given at the time of enrolment. I hereby allow Gan Shalom to take my child off school grounds for all trips, outings, and walks.
 
Photography Consent
I hereby give Gan Shalom Preschool and Daycare permission to photograph my child for public use.

Parent/Caregiver Contract

I hereby make application for the enrollment of my child as a pupil at Gan Shalom Preschool and Daycare for the year 2022/2023.

With my school application I am including my first month's tuition as a deposit. I understand that this deposit is non-refundable under any circumstances.

With my camp application, I am including a payment for half of July’s tuition dated for the date of registration. I understand that this deposit is non-refundable. I am also including the other half of July’s tuition, post-dated for March 1, 2022 and my August payment, post dated for August 2022.

I understand that I am required to give a month’s notice at the beginning of the month (or be charged for that month) and will ONLY be refunded for the months my child will no longer be attending.

I agree to abide by the rules and regulations of the school. 

I have read, understand and agree to abide by ALL school policies as per above (including Permission to Receive Emergency Care, Photography Consent and  Parent/Caregiver Contract) and our
Parent Handbook .

*Parent’s signature:

Referred by: 

AttentionImportant
To secure your spot, include (if you are on Fee Assistance, only forms are necessary):

GAN SHALOM CAMP CHECKLIST

If enrolling in Camp and School

Add 2 post dated cheques for tuition (July-August 2022)

If enrolling ONLY for Camp
* July’s tuition fee as deposit, post dated for March 1, 2022
(Please note: Should you withdraw from camp anytime after May 1st, this deposit is non-refundable
* August cheque, post dated for August 2022
* Completed registration forms (this electronic form and
Carpool Form - print and submit)
* Up to date immunization forms

GAN SHALOM SCHOOL CHECKLIST
* First month's tuition fee as a  non-refundable deposit (dated for the date of registration)  
* 9 post dated cheques from October 2022-June 2023
* Completed registration forms (this electronic form and
Carpool Form - print and submit)
* Up to date immunization forms  
Please Note: Your registration will not be accepted without all of the above items

Please keep in mind, that we do our best to accommodate all ‘same group’ requests but we cannot guarantee that all requests will be possible.

PLEASE NOTE: You will receive a Childcare Receipt for your payments at the end of the tax year. If you would like a donation receipt (for 25% of tuition), please request it before the end of the tax year.

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