Limmud b'Shabbat 5782 /2021-2022

Applicant Information

Student Information

First Name

Middle Name

Last Name

Nick Name

Hebrew Name

Date of birth

Time of Day

Pronouns

Other Pronoun

Student Cell Phone (Required for Teen Track)

Student Email (Required for Teen Track; optional for others, only used by teacher, not added to any lists or shared)

Educational Background

Weekday School Name

Grade (as of September 2021)

Religious School (other than CBST)

Summer Camp attending in 2021

Student's special interests/activities

Commitments that may affect attendance at CBST

Please share any special learning needs. The information you share remains confidential, used by faculty solely to deliver the highest quality education for each student.

Please upload copy of most recent IEP or GIEP

Additional Information

Please share any strategies that have been successful in working with student. What motivates them to be their best selves?

Medical Information

Allergies (please list all applicable allergies)
Please mark N/A if not applicable to this child.:

Does student carry an epi-pen?

Does student use an inhaler?

Share medical information that CBST staff and medical professionals should know (e.g. chronic illness, medication taken and avoided, medical devices).
Please mark N/A if not applicable to this child.:

Physical limitations (e.g. mobility, visual perception, hearing)
Please mark N/A if not applicable to this child.:

Primary Physician Name

Primary Physician Phone Number

Primary Physician Address

Medical Insurance Carrier

Group/Policy Number

SF Contact ID

Household Information

If you need to add/change any information below that is non-editable, please let us know in the text box below or email children@cbst.org.

Adult 1 Information

First Name

Last Name

Pronouns

Other Pronoun

Relationship with Child

Name Student Calls Adult

Email Address

Cell Phone Number

Mailing Street Address

City

State

Postal/Zip Code

Please let us know of any changes to your contact information.

Is There an Adult 2?

Adult 2 Information

First Name

Last Name

Pronouns

Other Pronoun

Relationship with Child

Name Student Calls Adult

Email Address

Cell Phone Number

Important Family Information

Additional Adults in Household or other family information CBST should know

Names and birthdates of children in your household NOT currently enrolling

Significant family events/changes in the past year that CBST should know about (e.g. separation, birth/adoption of a sibling, illness (incl. COVID), death, new caregiver, move)

Share a snapshot of Jewish life in your family, such as:
• Celebrations of Shabbat, holidays, etc.
• Affiliation with another Jewish community (synagogue, JCC, etc.)
• Family members who read or speak Hebrew
Please mark N/A if not applicable to this child.:

Describe other religions or cultures practiced in your family/extended family

Tell us what you most want your child to gain from their experiences at CBST this year

Authorisation

Emergency Contacts

If the adult(s) listed cannot be reached, I give permission for CBST to share information regarding my child with the following people:

Name

Relationship

Phone

Name

Relationship

Phone

Dismissal Release

Dismissal Preferences

My child may ONLY be released to adults listed in this household.In addition to the adults listed in this household, I give permission for my child to be released to the following adults with photo ID: I give permission for my child, age 13+ to be released independently upon dismissal by CBST Staff (younger siblings must still be picked-up by an adult).

-Early pick up or changes to this authorization must be received in writing, at least 24-hours in advance (CBST staff are not available by phone or email on Shabbat).

Name

Relationship

Phone

Name

Relationship

Phone

Additional Releases

PHOTO/AUDIO/VIDEO/WEBSITE/SOCIAL MEDIA RELEASE:
I give permission for images and audio of my child taken at CBST activities to be used in CBST’s PR/marketing.

FAMILY DIRECTORY RELEASE:
I give permission for my contact information to be shared with other parents in my child's class. Our intention is to create a directory, only for Limmud families.

FIRST AID RELEASE:
I consent to have CBST staff provide general first aid to my child.

EMERGENCY MEDICAL TREATMENT RELEASE:
In case of medical emergency, I authorize CBST staff to follow instructions and permit medical treatment for my child by medical authorities (i.e. 911 operators, emergency medical technicians, hospital and medical facility personnel, physician). I understand that I am responsible for all such emergency medical costs incurred.

Electronic Signature

Date

Electronic Signature

Date

Payment Information

Tuition

Membership in good standing (including completion of past-due tuition) is pre-requisite
Registration cannot be processed without payment
In case of cancellation, CBST cannot provide refunds after October 1, 2021

Grades K, 1, 2 3, 4, 5
$1,600 OR
$1,400 Early Bird Discount, available till 6/30

Grade 6 & 7 B’nai Mitzvah Program
$2,700 OR
$2,500 Early Bird Discount, available till 6/30

Teen Track (8-12) Limmud + Civil Rights Trip to the South
$2,400 OR
$2,200 Early Bird Discount, available till 6/30

Select grade program

Tuition Rate

$

Payment Options

If paying by ACH/eCheck or Credit Card, payment is in full. If you are requesting an installment plan or scholarship, please select that option below in the Payment Options dropdown menu.

Payment Options

CBST is committed to seeing that no child is denied a Jewish education due to financial circumstances.
A limited number of need-based scholarships are available in response to requests made by June 30, 2021.
Contact Yolanda Potasinski, Executive Director at ypotasinski@cbst.org or 212-929-9498 ext. 811 by June 30th.

Scholarship Fund: Consider a donation, at your discretion, to allow Jewish learning for students who would not otherwise be able to attend. Thank you!

$

Payment Amount

$

Scholarship Payment Amount

$

Preferred Payment Plan

Payment Information

Credit Card No.

Credit Card Type

Exp. Month

Exp. Year

Verification Code

Bank Routing Number

Bank Account Number

Bank Account Type

Bank Name

Account Holder Name

Billing Street

Billing City

Billing State

Billing Postal Code

Billing Country

Account Name

Learner Contact Id

Authnet_Hidden_Fields

ADHD / ADD	English is not student’s primary language
Academically gifted	Autism Spectrum Disorder
Difficulty understanding spoken or written instructions	Behavioral needs
Dyslexia	Student has an IEP or GIEP
Other (note below)