Child’s Name: ________________________________ Date of Birth: ______________________
Address: ______________________________________________________________________
City: __________________________________________ Zip Code: _______________________
Home Phone: __________________________________________________________________
Parent/Legal Guardian Name: _____________________________________________________
Work Number: ____________________________ Cell Number: _________________________
E-Mail Address: _________________________________________________________________
Parent/Legal Guardian Name: _____________________________________________________
Work Number: ____________________________ Cell Number: _________________________
E-Mail Address: _________________________________________________________________
Synagogue Affiliation: ____________________________________________________________
How did you hear about the preschool program? ______________________________________
Scheduling Options
Expected Start Date:_______________________
Toddler, Preschool & Pre-K Program: 16 mo. – 5 yrs.
Number of
Half Day
Member of
Bet Shalom
Half Day
Full time
Member of
Bet Shalom
Full time
Full-time Program– 2, 3, 4 or 5 days a week
o Monday-Thursday 7:00am-6:00pm
o Friday 7:00am-5:00pm
o Please mark the days you wish to attend:
Monday___Tuesday___ Wednesday___Thursday___Friday___
Your child does not need to stay for the entire day. They can arrive and depart as needed but
the full day of care will always be available to you when signing up for full-time care.
Part Time Program – 2, 3, 4 or 5 days a week
o Monday – Friday 9:00am-1:00pm
o Please mark the days that you wish attend:
Monday___Tuesday___Wednesday___Thursday___ Friday___
o Extended care can be used with the half day program. Extended care is available
between 7:00 am and 9:00 am and 1:00pm and 4:00pm Monday through Friday.
Extended care costs $13.00 per hour.
o Please mark the days you will need extended care and indicate the hours of
extended care needed:
Monday________________ Tuesday________________ Wednesday________________
Thursday_________________ Friday________________
If you would like to switch days in your child's schedule, please provide the Director one month notice in
advance by the first of the month. If approved, Director will notify you by mid month via email. (For
example, if you would like to switch from Tuesday, November 8th to Friday, November 11th, please notify
Director by October 1st. Director will let you know if it is approved by mid October.)This assures the
required staff to child ratio. The Director will accommodate when possible based on teacher/child ratio.
**Excludes scheduled holiday and school closures.
I understand that enrollment is based on availability of space in an age appropriate class. A
non-refundable deposit of $100 must accompany this form. This deposit will be applied to
your first month’s tuition costs. If you decide to not enroll your child at Bet Shalom Yeladim,
then your $100 will not be refundable.
____ I understand the policies regarding registration and enrollment.
PARENT SIGNATURE:____________________________________________________________
DATE: ______________________