HS Reg e-Form

Address*

Father's Address

Mother's Address

Mother's E-mail
Mother's Cell

Area Code Phone Number
Mother's Facebook Name
Marital Status of Parents:

MarriedSeparatedDivorced
If Divorced - How Long?
EMERGENCY INFORMATION
In case of emergency, when neither parent can be reached, please list two contacts who will take responsibility for your child:
Emergency Contact 1*
First Name Last Name
Relation to Child*
Phone Number*

Area Code Phone Number
Business Phone

Area Code Phone Number
Emergency Contact 2*
First Name Last Name
Relation to Child*
Phone Number*

Area Code Phone Number
Business Phone

Area Code Phone Number
CONFIDENTIAL: Does your child have any allergies or other medical condition we should be aware of? If yes, please describe them and indicate special precautions or care needed.
If parents cannot be reached and emergency medical advice is needed, permission is given to the Hebrew School staff to phone my child’s doctor:
Doctor*
First Name Last Name
Doctor's Phone Number*

Area Code Phone Number

Doctor's Address*

Doctor's Hospital Affiliation*
Authorization*

In case of emergency requiring immediate emergency care, I authorize the paramedics to take my child to the nearest hospital if necessary.
PAYMENT PLAN
Tuition per year:
Sundays $900 + Registration and Security Fee: $150
Tuition*

Sundays 10:30am-12:30pm - $900+$150
Tuition - Child 2*

Sundays 10:30am-12:30pm - $900+$150
Tuition - Child 3*

Sundays 10:30am-12:30pm - $900+$150

Payment type*

Credit Card Cash or Check

Postal / Zip Code

Country

Total

$0.00
Confirmation*

I understand that by submitting this form I am comitting to pay the above outlined tuition fees.
Full Name*
First Name Last Name
Initials*
Date*

Month Day Year
Should be Empty:

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