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ECLC Student Health Form 2024-2025
Please verify reCaptcha before submitting the form.
Thank you for enrolling in the VBS Etz Chaim Learning Center (ECLC) Hebrew School! This form is for families who have already paid their VBS membership and ECLC registration. If you have not yet renewed your VBS membership, please visit
vbs.org/eclcrenew
to complete the process.
*
How many children are you enrolling in the ECLC?
Please Select One
1
2
3
4
Student 1 Information
Student 1 First Name
Student 1 Last Name
Student 1 Gender
Student 1 Date of Birth
Student 1 Secular School
Student 1 Life Sustaining Medication
Student 1 Medical Conditions
504 or IEP in Place?
Does your child have a 504 or IEP in place at their secular school?
If yes, please provide additional details so we can better support your child's success in our school.
Student 1 Medical Insurance
Student 1 Insurance ID
Student 1 Doctor
Student 1 Doctor Phone Number
Student 1 Date of Last Tetanus Shot
Student 2 Information
Student 2 First Name
Student 2 Last Name
Student 2 Gender
Student 2 Date of Birth
Student 2 Secular School
Student Classmate Request
Students may request up to 3 classmates. Only ONE classmate is guaranteed.
Student 2 Life Sustaining Medication
Student 2 Medical Conditions
Student 2 Medical Insurance
Student 2 Insurance ID
Student 2 Doctor
Student 2 Doctor Phone Number
Student 2 Date of Last Tetanus Shot
Student 3 Information
Student 3 First Name
Student 3 Last Name
Student 3 Gender
Student 3 Date of Birth
Student 3 Secular School
Student Classmate Request
Students may request up to 3 classmates. Only ONE classmate is guaranteed.
Student 3 Life Sustaining Medication
Student 3 Medical Conditions
Student 3 Medical Insurance
Student 3 Insurance ID
Student 3 Doctor
Student 3 Doctor Phone Number
Student 3 Date of Last Tetanus Shot
Student 4 Information
Student 4 First Name
Student 4 Last Name
Student 4 Gender
Student 4 Date of Birth
Student 4 Secular School
Student Classmate Request
Students may request up to 3 classmates. Only ONE classmate is guaranteed.
Student 4 Life Sustaining Medication
Student 4 Medical Conditions
Student 4 Medical Insurance
Student 4 Insurance ID
Student 4 Doctor
Student 4 Doctor Phone Number
Student 4 Date of Last Tetanus Shot
Child/Children lives with
Please Select One
Both Parents
Mother
Father
Guardian
Other
If other:
*
Number of Parents/Legal Guardians to add
Please Select One
1
2
3
4
Parents are:
Please Select One
Married
Divorced
Separated
Widowed
Parent 1 First Name
Parent 1 Last Name
Parent 1 Relationship to Child
Parent 1 Home Address
Parent 1 City
Parent 1 State
--Select State--
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Parent 1 Zip
*
Parent 1 Home Phone
*
Parent 1 Mobile Phone
Parent 1 Business Phone
Parent 1 Occupation
*
Parent 1 Email
Parent 2 First Name
Parent 2 Last Name
Parent 2 Relationship to Child
Parent 2 Address
Please Select One
Same address as Parent 1
Enter new address
Parent 2 Home Address
Parent 2 City, State Zip
*
Parent 2 Home Phone
*
Parent 2 Mobile Phone
Parent 2 Business Phone
Parent 2 Occupation
*
Parent 2 Email
Parent 3 First Name
Parent 3 Last Name
Parent 3 Relationship to Child
Parent 3 Address
Please Select One
Same address as Parent 1
Enter new address
Parent 3 Home Address
Parent 3 City, State Zip
*
Parent 3 Home Phone
*
Parent 3 Mobile Phone
Parent 3 Business Phone
Parent 3 Occupation
*
Parent 3 Email
Parent 4 First Name
Parent 4 Last Name
Parent 4 Relationship to Child
Parent 4 Address
Please Select One
Same address as Parent 1
Enter new address
Parent 4 Home Address
Parent 4 City, State Zip
*
Parent 4 Home Phone
*
Parent 4 Mobile Phone
Parent 4 Business Phone
Parent 4 Occupation
*
Parent 4 Email
ENROLLMENT AND RESPONSIBILITY AGREEMENT
By typing below, I am acknowledging and agreeing to the following:
1. I/We understand that my/our child/children may not attend VBS Etz Chaim Learning Center unless I am a/we are member(s) in good standing of Valley Beth Shalom and that I/we have paid the full amount of the non-refundable tuition required for my/our child/children grade level(s). Should I/we need assistance with tuition it is my/our responsibility to contact the Valley Beth Shalom Administrative Office to set up the terms and conditions of my/our payment plan.
2. I/We understand that the Etz Chaim Learning Center will enforce a behavior management policy, and that all students are required to adhere to school and classroom policies as stipulated in the Etz Chaim Learning Center responsibility agreement in the parent/student guide. I/We understand that serious infractions such as, but not limited to, stealing, fighting, possession of contraband on campus (weapons, drugs or alcohol), willful destruction of school property, and/ or bullying (including sexual harassment) will result in an immediate removal from class and dismissal with no refund of tuition.
3. The Etz Chaim Learning Center makes no representations or guarantee as to any particular educational or social outcomes for my/our child/children. I understand that VBS may change its course offerings and activities, as well as its policies, procedures and practices, from time to time as circumstances may warrant, in its sole discretion.
4. Delinquency of payments due under this Enrollment Agreement may, at VBS' sole discretion, result in the suspension or dismissal of my/our child/children, from the Etz Chaim Learning Center.
5. I/We understand that the duties and obligations of the Etz Chaim Learning Center under this Agreement may be suspended immediately without notice during all periods that the it is closed or otherwise unable to perform its obligations under this Agreement because of force majeure events. A force majeure event shall mean any cause beyond the School’s control that prevents, delays, or otherwise interferes with the School’s performance of its obligations under this Agreement, and by way of example only, includes, but is not limited to fire, earthquake, flood, storm, accident, extreme weather events, acts of God, war, governmental action, terrorism, epidemic, pandemic, strike, or work stoppage. If such an event occurs, the School shall have no liability nor shall it be deemed to be in breach of this Agreement for any delay or failure to perform its duties and obligations in this Agreement, which may be suspended or postponed, at the sole discretion of the School. The School may also alter its calendar, provide alternate means of instruction, or take any other action it deems appropriate under the circumstances. In the event the School is unable to perform its obligations under this Agreement, or such performance is delayed or interfered with as a result of a force majeure, the School shall not be liable for any damage, remedy, or tuition refund. A closure or suspension of services due to a force majeure event shall not relieve me of any obligation, including, without limitation, payment obligations pursuant to this Agreement.
I/We have read, understood and agree to be bound by this enrollment agreement for myself/ourselves and on behalf of my/our child/children.
*
PLEASE TYPE NAME BELOW TO AGREE
MEDICAL EMERGENCY RELEASE
In the event of a medical emergency, in accordance with the VBS Etz Chaim Learning Center’s emergency procedure, I/we, the undersigned parent(s)/legal guardians, do hereby release the appropriate personnel of Valley Beth Shalom to either administer first aid OR release the child/children to an emergency hospital or disaster center, for further treatment, as they deem necessary. Furthermore, I/we authorize appropriate personnel of Valley Beth Shalom acting on behalf of VBS Etz Chaim Learning Center, to consent to all emergency medical care for this child/children to be rendered by a duly licensed physician, surgeon, dentist and/or other medical professional. This care may be given under whatever conditions are necessary to preserve the health and safety of the child. I/we further agree to pay all charges for that care and/or treatment. It is understood that if time and circumstances reasonably permit, VBS Etz Chaim Learning Center personnel will try, but are not required, to communicate with me/us prior to.
*
PLEASE TYPE NAME BELOW TO AGREE
PICK UP RELEASE
In accordance with the VBS Etz Chaim Learning Center’s emergency procedures, I authorize the release of my child/ children to the following (list below contacts that are located within close proximity to the school):
Number of people to allow to pick up
Please Select One
None
One Person
Two People
Three People
*
Pickup Name One
*
Pickup Phone One
*
Pickup Name Two
*
Pickup Phone Two
*
Pickup Name Three
*
Pickup Phone Three
*
Out of State Contact
*
Out of State Contact Phone
PHOTO/AUDIO/WEBSITE RELEASE
I give permission for photographs, slides, video or audio to be taken of my child/children to be used for the VBS Etz Chaim Learning Center calendar, website, public relations and promotional purposes. I understand that none of the above may be used by the mass media for newspaper or television stories without my consent for usage.
*
PLEASE TYPE NAME BELOW TO AGREE
FIELD TRIP
R
ELEASE
I give permission and consent to VBS Etz Chaim Learning Center and its employees and agents to take my child/children on field trips as part of the normal curriculum and, to the extent possible, absolve VBS Etz Chaim Learning Center and Valley Beth Shalom and its employees and agents from any liability for personal injury to my child or property damage, except for injuries resulting from gross negligence of VBS Etz Chaim Learning Center, Valley Beth Shalom or their employees or agents.
I understand that for all field trips that require transportation, I will receive a permission slip. Unless I have signed the permission slip my child will not be permitted to go on the trip.
*
PLEASE TYPE NAME BELOW TO AGREE
Fri, December 27 2024 26 Kislev 5785