2021-22 New Student registration form

B"H

Hebrew School Registration - New Student
School Year 2021 - 22

Please complete one form per student.

Family Information

Family Name*

Street Address*

City, State, Zip*

Student's Information

Student's Full Name*

Student's Hebrew Name

gender*

boygirl

Birthdate*

MonthDayYear

Grade entering 8/21*

School attending*

Previous Hebrew School Education

Name of previous Hebrew School (or indicate none)*

dates attended

How proficient is your child in Hebrew Reading?*

doesn't readpoorfairgood

Does your child have any learning difficulties with general studies?*

NoYes. If yes, please use the text box below to explain.

Child's learning difficulties

Is there any medical or other information which our school should be aware of?*

NoYes. Please use the text box below to explain.

Medical or other info we should be aware of:

Were there any conversions or adoptions in your family?*

NoYes. Please use the text box below to explain.

Conversions or adoptions

Is the child's natural mother Jewish?*

NoYes

Synagogue with which your family is affiliated (or indicate none)*

Parents' Information

Father's name*

Father's address, if different from above

Father's email address*

Father's cell phone*

Mother's name*

Mother's address, if different from above

Mom's email address*

Mother's cell phone*

Emergency Information

Please list a LOCAL person who may be contacted to pick up your child in case of an emergency when the parents cannot be reached.

Emergency Contact Name*

Emergency Contact relationship to child*

Emergency Contact cell phone #*

Family Doctor*

Doctor's Phone Number*

Fees and Payment Information

Registration & Book fee: $50/child
Tuition: $850; $425 for new families
note: For new families, we give a 50% discount.
For returning families, we give you a 10% tuition discount for additional children.

Tuition & Fees for Child #1*

$900 for returning family$475 for new family

Total

$0.00

Indicate your choice of Payment Plan*

one payment in full2 installments (September & January)9 monthly installments (September - May)

Payment*

Credit Card Paypal Check or Credit Card on file

Payment Instructions

Permission*

I hereby permit my child to participate in all school activities and to participate in class and school trips on and beyond school properties. In case of an emergency, I hereby authorize the school to have my child given care by a physician in the manner in which the situation dictates.

Signature*