B"HHebrew School Registration - New Student School Year 2022 - 23Please complete one form per student.Family InformationFamily Name*Street Address*City, State, Zip*Student's InformationStudent's Full Name*Student's Hebrew Namegender*boygirlBirthdate*MonthDayYear Grade entering 8/22*School attending*Previous Hebrew School EducationName of previous Hebrew School (or indicate none)*dates attendedHow proficient is your child in Hebrew Reading?*doesn't readpoorfairgoodDoes your child have any learning difficulties with general studies?*NoYes. If yes, please use the text box below to explain.Child's learning difficultiesIs 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 adoptionsIs the child's natural mother Jewish?*NoYesSynagogue with which your family is affiliated (or indicate none)*Parents' InformationFather's name*Father's address, if different from aboveFather's email address*Father's cell phone*Mother's name*Mother's address, if different from aboveMom's email address*Mother's cell phone*Emergency InformationPlease 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 InformationRegistration & Book fee: $50/childTuition: $900; $475 for new families note: For new families, we give approximately 50% discount. For returning families, we give you a 10% tuition discount for additional children.Tuition & Fees for this Child*$950 for returning family$525 for new familyTotal$0.00Yes, I'd like to donate the cost of processing this transaction by adding 3%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 Credit CardVisaMasterCardAmerican ExpressDiscoverCredit Card TypeCredit Card NumberSecurity CodeName on Card1 - January2 - February3 - March4 - April5 - May6 - June7 - July8 - August9 - September10 - October11 - November12 - DecemberExpiration Month2022202320242025202620272028202920302031Expiration YearPaypal has been selected. Payment will take place on the next page.We will automatically use your cc info in our system. If you prefer to send a check please note in payment instructions.Payment InstructionsPermission*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*Submit Clear FormShould be Empty: This page uses TLS encryption to keep your data secure.