Keshet Registration 2025-2026 - Form

Child Information

* Child's Full Name

* Date of Birth

* Gender

Preferred Name/Nickname

Child’s Hebrew Name [if any]

* Address

* City

* State

* Zip

* Will this be his/her first time in a preschool program?

YesNo

Allergies (If Applicable):

Other (If Applicable):

Enroll in Lunch Bunch?

* Preferred Hospital:

* Phone Number

* Child's Dental Care:

* Phone Number

Vaccine Information

The New York State Department of Health requires the following vaccines for all students:

• Diphtheria and Tetanus toxoid-containing vaccine and Pertussis vaccine (DTaP or Tdap)
• Hepatitis B vaccine
• Measles, Mumps and Rubella vaccine (MMR)
• Polio vaccine
• Varicella (Chickenpox) vaccine
• Haemophilus influenzae type b conjugate vaccine (HiB)
• Pneumococcal Conjugate vaccine (PCV)

For more information, check out the Department of Health website on vaccines.

Vaccination Information

Developmental Information

Please explain any concerns that you may have about your child's development:

Social:

Emotional

Physical

Other

Enrollment Information

* Name of Person Enrolling Child

* Relationship to Child

* Phone Number of Person Enrolling Child

* Email Address of Person Enrolling Child

Address of Person Enrolling Child (If Different)

Emergency Contact Information

* Emergency Contact 1 Full Name

* Authorized to Pick Up Child?

YesNo

* Primary Phone Number

* Emergency Contact 2 Full Name

* Authorized to Pick Up Child?

YesNo

* Primary Phone Number

Emergency Contact 3 Full Name

Authorized to Pick Up Child?

YesNo

Primary Phone Number

Transportation

NYS requires 3 adults in addition to parents/guardians who are authorized for pickup. These can be the same as emergency contacts.

Full Name | Pickup 1

Phone Number

Full Name | Pickup 2

Phone Number

Full Name | Pickup 3

Phone Number

Primary Parent Information

* Parent/Guardian Full Name

* Email Address

* Phone Number

* Authorized for Pickup?

YesNo

* Occupation

* Are you Jewish?

YesNo

Home Address (if different from child)

Secondary Parent Information

Parent/Guardian Full Name

Email Address

Phone Number

Occupation

Are you Jewish?

YesNo

Enroll in Enrichment?

Program Selection

* Are you a member of any Rochester synagogue?

If other, where?

* Child's age of December 1, 2025

Days per week:

2 Days a Week3 Days a Week18-24 month old children are eligible for 2 and 3 day weeks.

Days to attend:

TuesdayWednesdayThursday

Days per week:

2 Days a Week3 Days a Week5 Days a Week2-year-old children are eligible for 2, 3, and 5 day weeks.

Days per week:

3 Days a Week5 Days a Week3-year-old children are eligible for 3 and 5 day weeks.

5 Days a Week

5 Days a Week4-year-old children are eligible for a 5 day week only.

* Child's age of December 1, 2025

Days per week:

2 Days a Week3 Days a Week18-24 month old children are eligible for 2 and 3 day weeks.

Days to attend:

TuesdayWednesdayThursday

Days per week:

2 Days a Week3 Days a Week5 Days a Week2-year-old children are eligible for 2, 3, and 5 day weeks.

Days per week:

3 Days a Week5 Days a Week3-year-old children are eligible for 3 and 5 day weeks.

5 Days a Week

5 Days a Week4-year-old children are eligible for a 5 day week only.

Enrichment & Add-Ons

Lunch Bunch: All students are eligible for Lunch Bunch, held for one hour after the Keshet school day, for $16 per day. This registration is by individual semesters. Enrichment offerings will be release by July 1.

Enrichment: Students ages 3 and 4 are eligible for Enrichment, held for one hour after Lunch Bunch, for $37 per day. This includes the price of Lunch Bunch, and final Enrichment offerings will be available soon. This registration is by individual semesters.

Early Drop Off: All students are eligible for Early Drop Off up to one hour before the Keshet school day begins, for $18 per day. This registration is for the entire year.

Enroll in Enrichment?

Enroll in Lunch Bunch?

Fall | Enrichment Days/Week

Spring | Enrichment Days/Week

Fall | Lunch Bunch Days/Week

Spring | Lunch Bunch Days/Week

Permissions

My child, named above, has permission to attend all supervised field trips and activities of Keshet Preschool from September 2025 – June 2026. I/We understand that reasonable vigilance in the care and supervision of the children will be exercised. Beyond this I/We will not hold the school or those supervising the trip responsible.

* Signature of Parent or Guardian

* Date of Initial

I authorize the use of photographs of my child for all Keshet advertising. No names will ever be used without additional parent permission.

I authorize the use of my child's photograph for in-house purposes only, including newsletters and emails.

Pandemic Information

Please note that in the event that we need to shut down for any pandemic, you have the right to choose if your child continues with digital learning. If you do choose this option, you will be given materials for two weeks at a time, as well as access to daily virtual lessons on the days your child attends. If you do not choose to have your child continue digitally, you will not receive materials or have access to digital learning. You will receive a credit for the amount of time we are closed.

Voluntary Contribution for Security

Security is provided at all times children are on the property. This is not covered by tuition, so please consider helping us offset that cost.

Other:

Agreements

* I consent to emergency medical treatment for my child

Please Select OneYesNo

* I consent for my child to take part in neighborhood trips away from the program under proper supervision

Please Select OneYesNo

* I understand the program may need additional permissions for situations such as transportation, medication, release of information, and field trips

Please Select OneYesNo

* I provided information on my child's special needs to the program to assist in caring for my child

Please Select OneYesNo

* I understand the program must give parents, at the time of enrollment of a child, a written policy statement as required by regulation

Please Select OneYesNo

* I agree to review and update this information whenever a change occurs and at least once every year

Please Select OneYesNo

* I understand that I will have to provide a physical signature on or before the first day of school in accordance to NYS regulations

I understand that I will have to provide a physical signature on or before the first day of school in accordance to NYS regulations

* This agreement is made between Temple Beth El, on behalf of Keshet Preschool, 139 Winton Road South, Rochester, NY 14610 and the undersigned parent(s) or guardian(s) of:

Parental Agreement

* We have read and understand this enrollment contract and agree that by signing below it we accept responsibility for all financial obligations contained herein.

Financial Agreement

* Persons(s) responsible for payments to Temple Beth El (please type names below, this will act as a legal signature).

Payer Agreement

* I understand that, if paying by charge card, there will be a 3% surcharge applied to offset necessary system fees. If you would like to pay by paper check, please call the office at (585)473-1770 to discuss options.

Credit Card Agreement

A payment plan must be set up upon confirmation with full payment due by April 30, 2026. If you do not set up a plan, one will be set up for you, recurring on the 1st of every month starting September 1, 2025.