Hebrew School Registration Form

Address

Phone Number

Area Code Phone Number
E-mail
Child 1 (name and Hebrew name)
Birth Date

Month Day Year
Child 2 (name and Hebrew name)
Birth Date

Month Day Year
Child 3 (name and Hebrew name)
Birth Date

Month Day Year
In case of injury of a child, every effort will be made to contact the parent or guardian.
In case of emergency, call:
Full Name
First Name Last Name
Phone Number

Area Code Phone Number
Full Name
First Name Last Name
Phone Number

Area Code Phone Number
Personal history:
Are the child/ren's parents living together?

YesNo

Mother's or father's address if different

Phone Number

Area Code Phone Number
Is the Maternal grandmother Jewish?

YesNo
Are there any conversions in the family?

YesNo
If yes

MotherFatherGrandmotherGrandfatherEarlier conversion
Please email conversion certificate
Does your child have any allergies? If yes please specify
Fees
$40 Per month
If more than one child is attending, please put in the correct amount in the area where you can fill in other total (e.g. 2 children would be $80 a month).
Payment options

Full payment of $360 submitted with this form8 postdated checks of $40recurring automatic monthly payment of $40 (please also check off the recurring option below)
$40$360
Yes, I'd like to make this a monthly recurring payment.

Payment

Credit Card Paypal Check

Postal / Zip Code

Country

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