New Student Register - Chabad Jewish Center Of Gilbert

GILBERT HEBREW SCHOOL REGISTRATION
2018-2019 School Year
Child's Name*
First NameLast Name
Hebrew Name
Birth Date*
MonthDayYear
Approximate Time of Birth
This info used to determine their Hebrew Birthday
Grade entering*
School*
Parents Information

Address*

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Father's Name*
First NameLast Name
Father Cell*
Area CodePhone Number
Father E-mail*
Employer
Position
Mother's Name*
First NameLast Name
Mother Cell*
Area CodePhone Number
Mother E-mail*
Employer
Position
Religious & Educational History
Previous Jewish Education
Does your child have any learning difficulties with general studies?*
If yes, please describe
Were there any conversions and/or adoptions in the family?*
If yes, please specify
Synagogue Affiliation
Medical Information
Up to Date with Vaccinations?*
YesNo
Are there any special medical, allergy or other information that I should be aware of?
Emergency Contact*
First NameLast Name
Phone Number*
Area CodePhone Number
Relation to Student*
City/Town*
Family Physician*
Phone Number*
Area CodePhone Number
Accident, Trip & Privacy Declaration:
Accident:As the parent or legal guardian of the above listed child, I authorize any adult acting on behalf of Gilbert Hebrew School to hospitalize or secure treatment for my child, I further agree to pay all charges for that care and/or treatment. It is understood that if time and circumstances reasonably permit, Gilbert Hebrew School personnel will try, but are not required, to communicate with me prior to such treatment.
Trips & Outings:I hereby give permission for my child to attend and participate in all trips and outings organized as part of the program by Gilbert Hebrew School.
Privacy:I hereby give permission for my child’s photographs/videos to be used in newsletters, local newspapers, Gilbert Hebrew website or for promotion of our program. I give permission for our family contact information to be shared with other families.
Authorization*
Click to confirm consent
Parent Signature*
Payment
Hebrew School Tuition is $505.
Tuition fees include all books, art materials and trips. Synagogue membership is not required. Affiliated and non-affiliated are welcome.
A $50 non-refundable deposit per child is due with registration. The deposit will be applied to tuition.
$35 Early Bird Discount for registration received by June 1, 2018.
10% discount for additional children in same family.
Payment Plans
Plan A: Pay full Tuition by August 1st, which entitles a $30 discount off the family's total tuition fees.Plan B: Automatically charge credit card on the first of each month, September – MayPlan C: Submit 9 postdated checks for the first of each month, dated August 1 through April 1
Request for Scholarship
Due to the needs and limits of our family, we would like to request a scholarship. Scholarship requests will be reviewed and responded to within 3 weeks of submission.
Scholarship Amount:
Amount we are prepared to pay towards our child’s Hebrew school tuition
Tuition Deposit*
$50
Additional Payment Toward Tuition to be paid upon submission of form.
$
Total
$0.00

Payment*

Credit Card

Credit Card Type
Credit Card Number	Security Code
Name on Card
Expiration Month	Expiration Year

Billing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Should be Empty:

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GILBERT HEBREW SCHOOL REGISTRATION

2018-2019 School Year

Parents Information

Religious & Educational History

Medical Information

Payment