Child’s Name: __________________________ Due Date/Birth Date: ______________________
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: _______________________________
Full-time Program– 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.
Monthly Tuition
(Full day program only)
Number of
Member of
Bet Shalom
**If your child’s schedule will vary by week or month, please provide that schedule to the
Director two months in advance on the 1
st 
of the month in question (For example: your child’s
schedule for September is due by July 1
and October’s schedule by August 1
). This assures the
best staff to child ratio. If the schedule changes within that two month window and you need
extra care, we will accommodate wherever possible based on the teacher/child ratio scheduled
at that time. Please note that two months’ notice is needed in order to decrease a child’s
I understand that enrollment is based on availability of space in an age appropriate class.
Congregants of Bet Shalom Congregation and presently enrolled families receive priority
enrollment. A non-refundable deposit of $100 must accompany this form. If we do not have
space for your child by expected start date, then the $100 is refundable. If you choose to not
enroll in Bet Shalom Yeladim and we do not have space for your child the $100 is refundable.
If we have space by one month of expected start date and you choose to not bring your child
to Bet Shalom Yeladim, your $100 is not refundable. If space becomes available and you
choose to enroll in Bet Shalom Yeladim, the $100 will come of your first month tuition.
____  I understand the policies regarding registration and enrollment.
PARENT SIGNATURE:____________________________________________________________
DATE: ______________________