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Hebrew School Registration Form

Hebrew School Registration Form

 
Student Information
CHILD 1
Last Name
First Name
Hebrew Name
Gender
Male Female
Date of Birth
School
Grade
Previous Jewish education?
Yes No
If Yes please describe
Medical Information -
Any Medical Challenges?
Yes No
If Yes please explain
 
CHILD 2
Last Name
First Name
Hebrew Name
Gender
Male Female
Date of Birth
School
Grade
Previous Jewish education?
Yes No
If Yes please describe
Medical Information -
Any Medical Challenges?
Yes No
If Yes please explain
 
CHILD 3
Last Name
First Name
Hebrew Name
Gender
Male Female
Date of Birth
School
Grade
Previous Jewish education?
Yes No
If Yes please describe
Medical Information -
Any Medical Challenges?
Yes No
If Yes please explain
 
Parent Information
Marital Status
Affiliation
 
Father
Title/First Name
Last Name
Work Phone
Cell Phone
Occupation
Email
Mother
Title/First Name
Last Name
Work Phone
Cell Phone
Occupation
Email
Parents
Address
City/State/ Zip
Home Phone
Have there been any conversions or adoptions in the family? Yes No
If yes please explain
Emergency Information
Emergency 1
Name
Phone #
Relation
Emergency 2
Name
Phone #
Relation
Tuition Fees

Classes are held on Monday or Thursday Afternoon at Center for Jewish Life 4:00 - 6:00 PM

Please select below.

My Child(ren) will be attending classes on Monday Or Thursday
$950.00 Tuition * Charitable tax receipts will be issued for the full amount of all tuition fees paid.
5% Discount for additional child.
5% Discount for a friend referral | Friend Name
Payment Information
Please Choose Payment Plan
Please Choose Payment Method
(Due to credit card company fees, Visa will be processed with an additional 2% surcharge and 4% for Master Cards.)
Card Number
Name on Card
Expiration Date
Security Code
What's This?
Billing Address
Billing Zip
I would like to assist a child who cannot afford Hebrew School Education.
Disclaimer
I heard about the Hebrew School from
Digital Signature

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