Mercaz & Youth Group Registration 2025-2026 - Form

Please note that payment is required to complete this registration.

Parent/Guardian Information

* Parent/Guardian 1 First Name

* Parent/Guardian 1 Last Name

* Parent/Guardian 1 Email

* Parent/Guardian 1 Cell Phone

* Address 1

Address 2

* City

* State

* Zip Code

* Parent/Guardian 2 First Name

* Parent/Guardian 2 Last Name

Parent/Guardian 2 Email

Parent/Guardian 2 Cell Phone

Is Parent/Guardian 2's Address different from Parent/Guardian 1?

NoYes

* Address 1

Address 2

* City

* State

* Zip Code

Student Information

Grade and Days	Tuition Fees Per Student
Pre-K through 2nd Grade Sundays Only \| 9:00 am 12:00 pm	$630 Member $890 Non-Member
3rd Grade through 6th Grade Sundays \| 9:00 am - 12:00 pm Wednesdays \| 4:30 pm - 6:30 pm	$985 Member
6th Grade Shalom School Only Sundays \| 9:00 am - 12:00 pm Wednesdays \| 4:30 pm - 6:30 pm	$675 Member
7th Grade Wednesdays Only \| 4:30 pm - 6:30 pm	$630 Member

Please select the number of students to be registered.

STUDENT 1

* Student 1 First Name

* Student 1 Last Name

* Student 1 Gender

Student 1 Phone Number

* Student 1 Birthdate

* Student 1 Age as of 9/1/2025

* Student 1 Hebrew Name

Student 1 Current School

* Student 1 Entering Grade

This determines the Tuition and Fees per Student.

* Please list any allergies, including allergies to any medications:

* Student 1 is currently taking the following medications:

* Is there any other information we need to know relevant to Student 1's education?

We will ask for physician and dentist contact information later in this form.

STUDENT 2

* Student 2 First Name

* Student 2 Last Name

* Student 2 Gender

Student 2 Phone Number

* Student 2 Birthdate

* Student 2 Age as of 9/1/2025

* Student 2 Hebrew Name

Student 2 Current School

* Student 2 Entering Grade

This determines the Tuition and Fees per Student.

* Please list any allergies, including allergies to any medications:

* Student 1 is currently taking the following medications:

* Is there any other information we need to know relevant to Student 2's education?

We will ask for physician and dentist contact information later in this form.

STUDENT 3

* Student 3 First Name

* Student 3 Last Name

* Student 3 Gender

Student 3 Phone Number

* Student 3 Birthdate

* Student 3 Age as of 9/1/2025

* Student 3 Hebrew Name

Student 3 Current School

* Student 3 Entering Grade

This determines the Tuition and Fees per Student.

* Please list any allergies, including allergies to any medications:

* Student 3 is currently taking the following medications:

* Is there any other information we need to know relevant to Student 3's education?

We will ask for physician and dentist contact information later in this form.

Code of Conduct

The Mercaz Religious School and Youth Group Code of Conduct Regarding Bullying must be acknowledged for each student being enrolled. Please click here to view the Code of Conduct Regarding Bullying.

* I have received a copy of the Mercaz Religious School and Youth Group Code of Conduct Regarding Bullying and have discussed it with my child.

I have received a copy of the Mercaz Religious School and Youth Group Code of Conduct Regarding Bullying and have discussed it with my child.

Name/Photo/Release

By checking “Yes” on this consent form, I give permission for my child(ren)’s first and last names and/or photograph to be used in publications, presentations, videos, or Web pages, or news releases produced by Mosaic Law Congregation’s Religious School and Youth Groups. My child(ren)’s first and last names and/or photograph may be included in news releases distributed to newspapers and other news media.

Yes, I give permission for my child(ren)’s to be photographed or videotaped while in school or during school-related activities outside the classroom for internal use only, not for public distribution as listed above.
NOTE: No payment will be made to a child photographed under terms of this release or to his/her family if and when the photographs are used in district publications, presentations, video productions, or Web sites. Parents/Legal Guardians waive the right to preview or approve the finished photographs or video.

By checking "No", I do NOT want my child(ren)’s first and last names released nor my child(ren) to be photographed or videotaped while in school or during school-related activities outside the classroom.

Checking “No” means that my child(ren)’s first and last names and/or photograph may NOT appear in any Mosaic Law Congregation’s Religious School publication, synagogue bulletin board, presentation, video, website, or news release produced by Mosaic Law Congregation’s Religious School.

* Photo Release

Please Select OneYes - full use permittedYes - internal use onlyNo - no pictures

* Preference for Social Media Alerts, Reminders, and Information

Please Select OneYES - I give permission be invited to be a part of social media alerts, reminders, and information.NO - I do NOT give permission to permission be invited to be a part of social media alerts, reminders, and information.

* Preference for Texts

Please Select OneYES - I give permission to receive texts.NO - I do NOT give permission to receive texts.

Emergency Contact Information

* Emergency Contact Name

* Emergency Contact Relationship

* Emergency Contact Phone Number

* Emergency Contact Name

* Emergency Contact Relationship

* Emergency Contact Phone Number

Authorization For Emergency Medical Treatment

The undersigned, as parent/legal guardian of Student, hereby authorizes the Education & Youth Director or designee, into whose care the Student has been entrusted, to consent to any X-ray examination, anesthetic, medical, surgical, or dental diagnosis, treatment, and/or hospital care to be rendered to the Student upon advice of any licensed physician and/or dentist. It is understood that this authorization is given in accordance with Section 49407 of the California Education Code and shall remain effective until revoked in writing and delivered to Mosaic Law Congregation. I understand that Mosaic Law Congregation, its officers, and its employees assume no liability of any nature in relation to the transportation of the Student. I further understand that all costs of paramedic transportation, hospitalization, or any examination, X-ray, or treatment provided in relation to this authorization shall be my sole responsibility as the Student’s parent/legal guardian.

* Physician

* Physician Phone Number

* Hospital Preference

* Medical Insurance ID#

* Dentist

* Dentist Phone Number

* Dental Insurance ID#

Total Tuition and Fees

Once you select submit below, you will be taken to a page to pay for the tuition and fees.