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Annual Fundraiser David Broza Concert 5-15-25
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Pre-School Interest Form
Please verify reCaptcha before submitting the form.
*
Family Last Name
*
Todays date
Date to begin school
*
Which are you interested in receiving information for?
Preschool School Year
Preschool Summer Camp
Please click all that apply.
*
Address
*
City
*
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
*
Zip Code
*
How many students are being enrolled?
Please Select One
One student
Two students
Three students
*
Student 1 - First Name
*
Student 1 - Last Name
Student 1 - Nickname
*
Student 1 - Date of Birth
Student 1 - Gender
Student 2 - First name
Student 2 - Last name
Student 2 - Nickname
Student 2 - Date of Birth
Student 2 - Gender
Student 3 - First name
Student 3 - Last name
Student 3 - Nickname
Student 3 - Date of Birth
Student 3 - Gender
*
Parent/Guardian 1 - First Name
*
Parent/Guardian 1 - First Last
*
Parent/Guardian 1 - Email
*
Parent/Guardian 1 - Cell Phone
*
Parent/Guardian 1 - Birthdate
*
Are you and your family members at another synagogue?
Yes
No
*
If you are a member of another synagogue, please provide the synagogue name.
*
Free membership at Beth El for those enrolling in our preschool.
Yes, we are interested in receiving a free membership with Beth El as long as our oldest child is in your preschool.
No, thank you for the offer but we do not wish to have a free membership at Beth El.
Free membership is offered to those who enroll their oldest child in our Steinberg Preschool and pay the full tuition.
*
Does your child have older siblings? If yes, please include their name and birth dates here. If none, please type None.
*
Is there a second parent or guardian?
Please Select One
Yes
No
Parent/Guardian 2 - First Name
Parent/Guardian 2 - First Last
Parent/Guardian 2 - Email
Parent/Guardian 2 - Cell Phone
Parent/Guardian 2 - Birthdate
This field is REQUIRED if including 2nd parent.
*
Does Parent 2 live at the same address as Parent 1?
Please Select One
Yes
No
Parent/Guardian 2 - Address
Parent/Guardian 2 - City
Parent/Guardian 2 - 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/Guardian 2 - Zip Code
Mon, December 30 2024 29 Kislev 5785