2025-26 Lil'mud (Limmud Tot Class Registration)

Student Information

Student Name

Date of Birth

How does your child spend their weekdays? (ex. daycare, nanny, home with parent, etc.)

If you're not a member of Adat Shalom, would you like to receive membership information? Yes No

Home Information

Parent 1 Name

Parent 1 Cell

Parent 1/Billing/Primary Limmud Info Email

This address will receive a confirmation email

Address

Parent 2 Name

Parent 2 Cell

Parent 2 Email

Address

Tell us more!

In the event of an emergency, please assign another Limmud parent or local emergency contact for us to contact.

EMERGENCY Contact Name (Parents will be contacted first - this needs to be a NON-parent)

Emergancy Contact BEST Phone Number

I understand that I am expected to stay at Adat Shalom while my child is in class in case I need to be reached for diaper changes or emergencies.

Yes No- Please contact me for clarification

Is your child toilet trained?

Yes No, not yet We're working on it right now!

Does your child have any allergies?

Anything we should know about your child? Please Explain:

By submitting this form, you are consenting to the following:

Our/my child has our/my permission to participate in in-person programs with the Adat Shalom Reconstructionist Congregation.

We/I agree to release, hold harmless and indemnify Adat Shalom Reconstructionist Congregation (ASRC), as well as their agents, representatives and employees from all claims, damages, or other liabilities for injury to my child that might arise from my child’s participation in the Limmud program.

We/I understand that photographs and recordings of our/my child may be taken and shared for promotional purposes by Adat Shalom Reconstructionist Congregation (ASRC.)

If we/I choose to opt out of this photograph release, we/I must submit a separate notice via email to the Executive Director, Adat Shalom Reconstructionist Congregation.

By registering for Limmud I/We acknowledge that our child is up to date on all eligible vaccinations and boosters, including the COVID-19 vaccine and booster, unless there is a medical exemption.

Directions for Payment

Checks may be mailed to Adat Shalom.

Online Payments will have an added 3% fee. Please look at the fee schedule below, and enter the amount you want to pay in the payment field below.

Payment in full for Limmud 25/26 is due no later than December 15th, unless a prior arrangement is made with Adat Shalom.

We don't want cost to be a barrier to participation. Would you like the office to contact you regarding payment options?

Yes No

I understand that payment in full for Limmud 25/26 is due no later than December 15th, 2025, unless a prior arrangement is made with Adat Shalom.

Yes, I understand. No, I do not understand this. Please contact me for further clarification.

Tot Class:

-Members $50 a month
-Non-Members $75 a month

What month would your child begin Lil'mud? (Please note that your child can start when they are 18 months old)

September October November December January February March April May

Credit/Debit Card Number

Expiration Date/CVC

Name on Card Card Billing Address

2025-26 Lil'mud (Limmud Tot Class Registration)

Description

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