How many Family Members are you registering? *

Sholem Member Roster

This information will be published in our password-protected online roster. If you wish to omit any of your information from the online roster, you may opt out by unchecking the box to the left of the field(s).

Roster fields

Member Information

Parent Informaton

Name *

First

Last *

Last

Email *

Best Contact Phone *

Secondary Phone

Address *

Address

City

State/Province

Zip/Postal

Parent Skills and Interests

Second Family Member

Name

First

Last

Email

Preferred Phone

Third Family Member

Name

First

Last

Email

Preferred Phone

Fourth Family Member

Name

First

Last

Email

Preferred Phone

Parent 2 Information

(optional)

Student Enrollment

How many Students are you registering?

Do not include Belfer Students here. Use the separate section below

Student Information

Student Name *

First

Last *

Last

Student Date of Birth

School Grade

Vaccines

Has received all vaccinations required or recommended for primary or secondary school attendance

Is not fully immunized.

What should we know about this student's needs and abilities?

Bar/Bas Mitsve This Year

Enroll in Sholem's Bar/Bas Mitsve Program

Bar/Bas Mitsve Program $3000 plus $1030 Advisor fee. A discount coupon will be issued based on years of enrollment. Fee Table

Student 2 Information

Student Name *

First

Last *

Last

Student Date of Birth

School Grade

Vaccines

Has received all vaccinations required or recommended for primary or secondary school attendance

Is not fully immunized.

What should we know about this student's needs and abilities?

Bar/Bas Mitsve This Year

Enroll in Sholem's Bar/Bas Mitsve Program

$3000 plus $1030 Advisor fee. You should have a coupon code for a discount based on years of enrollment at Sholem. Fee Table

Student 3 Information

Student Name *

First

Last *

Last

Student Date of Birth

School Grade

Vaccines

Has received all vaccinations required or recommended for primary or secondary school attendance

Is not fully immunized.

What should we know about this student's needs and abilities?

Bar/Bas Mitsve This Year

Enroll in Sholem's Bar/Bas Mitsve Program

$3000 plus $1030 Advisor fee. You should have a coupon code for a discount based on years of enrollment at Sholem. Fee Table

Student 4 Information

Student Name

First

Last

Student Date of Birth

School Grade

Vaccines

Has received all vaccinations required or recommended for primary or secondary school attendance

Is not fully immunized.

What should we know about this student's needs and abilities?

Bar/Bas Mitsve This Year

Enroll in Sholem's Bar/Bas Mitsve Program

$3000 plus $1030 Advisor fee. You should have a coupon code for a discount based on years of enrollment at Sholem. Fee Table

Belfer Registration

I have a student(s) to register in the Belfer Program

Register Students in the Belfer Program Here

Belfer Student Name *

First

Last *

Last

Student Date of Birth

School Grade

Vaccines

Has received all vaccinations required or recommended for primary or secondary school attendance

Is not fully immunized.

What should we know about this student's needs and abilities?

Click the "Add" button below to add another Belfer Student

Add another Belfer Student Remove

Family Informaton

Does your child or family observe any particular dietary preferences?

Income Bracket *

Bracket A - 81% or above of median L.A. income

Bracket B - 51% – 80% of median L.A. income

Bracket C - 50% or less of median L.A. income

Click here to view the Median L.A. Income Table

Tution Grid

To lift up others, please look for the Donation link during checkout.

Regular Tuition

Subscription

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^{Monthly amounts for subscription}

Sholem Volunteering

The Sholem Community is a co-op that depends on its members to volunteer to help run the organization. We need each member family to do their part. Please review the list below and select at least one committee.

Areas where our family would like to help: *

Adult Activities: Politics & Culture
Plans activities for Sholem adults and members of the larger community. These may include lectures, forums, film screenings, book signings, social gatherings and more.

Adult Activities: Parent Programming
Plans activities for Sholem parents. These include programming specifically designed for parents of children under 18, addressing issues such as education and parenting.

Community Holidays
Subcommittees organize and produce Sholem’s observance of the New Year Festivals (Rosh Hashana, Kol Nidre and Yom Kippur); our secular Passover seder; our annual Mother’s Day brunch; and other holiday celebrations as needed.

Membership
Prepares and maintains registration, tuition, dues materials, and the roster.

Outreach
Responsible for publicity, advertising, press relations, and social media.

School
Coordinates teacher recruitment, hiring, and evaluation; assists the school principal with administrative tasks; and helps with curriculum development.

Social Action
Organizes activities to influence the wider community and educate ourselves about issues consistent with Sholem’s progressive, ethical values.

Digital
Maintains and enhances Sholem’s website, https://www.sholem.org. Assists with email lists, social media, and various digital needs for other committees as necessary.

Medical Consent

Parent Phone During Sholem Hours *

2nd Parent Phone During Sholem Hours

Emergency Contact Name *

First

Emergency Last *

Last

Emergency Contact's Phone *

Insurance Provider

Policy Number

Physician Name *

First

Physician Last Name *

Last

Physician's Phone *

Student Medical Information

List any special medical information, medication required, or conditions that may require attention:

Any allergies (to food or medications, etc.)?

In the event that I, or other parent/guardian, cannot be reached in an emergency, I give permission to the Sholem staff to secure proper treatment for my child. If the above physician cannot be reached, I authorize qualified emergency personnel to treat my child. I agree to accept financial responsibility for the costs related to this medical treatment. I acknowledge that it is my responsibility to keep the above information current. I also agree to notify the Sholem School if my child is exposed to any communicable disease.

Digital Signature

Photo/ Video Permission

Photo/Video Release *

Permission is granted to use photo/videos for the purposes described above.

Please do not use such photos/videos in Sholem communications.

Community Membership – Annual Subscription

Sholem Member Roster

Roster fields

Member Information

Parent Informaton

Second Family Member

Third Family Member

Fourth Family Member

Parent 2 Information

Student Enrollment

How many Students are you registering?

Student Information

Student 2 Information

Student 3 Information

Student 4 Information

Belfer Registration

Register Students in the Belfer Program Here

Family Informaton

Tution Grid

To lift up others, please look for the Donation link during checkout.

Sholem Volunteering

Medical Consent

Student Medical Information

Photo/ Video Permission

School Enrollment & Community Membership (monthly)