Registration

Hebrew School Registration 2020/2021
CHILD 1:
Full Name*
First NameLast Name
Hebrew Name
Gender*
MaleFemale
Birth Date*
MonthDayYear
Time of Birth
HourMinutes
School Attending*2019/2020
Grade*2019/2020
Past Hebrew Lessons*
No Previous HSPrivate Tutor
Please choose a program:*
Grades K-2: Sunday, Track 1Grades K-2: Sunday, Track 2Grades 3-6: Sunday, Track 1Grades 3-6: Sunday, Track 2Grades 3-6: Wednesday, Track 1Grade 7: Sunday, Track 1Grade 7: Sunday, Track 2Grade 7: Wednesday, Track 1
CHILD 2:
(if applicable)
Full Name
First NameLast Name
Hebrew Name
Gender
MaleFemale
Birth Date
MonthDayYear
Time of Birth
HourMinutes
School Attending2019/2020
Grade2019/2020
Past Hebrew Lessons
No Previous HSPrivate Tutor
Please choose a program:*
Grades K-2: Sunday, Track 1Grades K-2: Sunday, Track 2Grades 3-6: Sunday, Track 1Grades 3-6: Sunday, Track 2Grades 3-6: Wednesday, Track 1Grade 7: Sunday, Track 1Grade 7: Sunday, Track 2Grade 7: Wednesday, Track 1
Parents
Parent's Marital Status*
Child lives with*
Is the natural mother of the child Jewish?*
YesNo
Have their been any conversions or adoptions in the family?*
YesNo
If yes, please specify Rabbi & Congregation
PARENT 1:
Parent 1 Title*
Parent 1 Full Name*
First NameLast Name
E-mail*
Work Phone*
Area CodePhone Number
Cell Phone*
Area CodePhone Number
Occupation*
PARENT 2:
Parent 2 Title
Parent 2 Full Name
First NameLast Name
E-mail
Work Phone
Area CodePhone Number
Cell Phone
Area CodePhone Number
Occupation
HOME:

Home Address*

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

Home Phone
Area CodePhone Number
Emergency Contact Information
EMERGENCY CONTACT:
Full Name*
First NameLast Name
Phone Number*
Area CodePhone Number
Relation*
MEDICAL AND SPECIAL NEEDS:
Is your child taking permanent medications?*
YesNo
Any known allergies (incl. reactions to medications)?*
YesNo
Any present medical conditions?*
YesNo
Any learning disabilities?*
YesNo
If you answered yes to any of the questions above, please provide details:
PHYSICIAN:
Family Physician*
Phone Number*
Area CodePhone Number
Address*
General Information
OTHER PERSON AUTHORIZED TO PICK UP CHILD:
Name of Authorized Person
First NameLast Name
Cell Phone of Authorized Person
Area CodePhone Number
Relationship of Authorized Person
TRIPS:
I give permission for my child to participate on class trips throughout the school year:
Trips Permission:*
YesNo
Tuition and Billing
K-2nd Grade                                 Track 1 & Track 2
Member $250 and 7 Payments of 92.86 =$900
Non member $250 and 7 Payments of 128.57 =$1,150
3rd - 6th Grade                             Track 1 & Track 2
Member $250 and 7 Payments of 107.15 =$1000
Non member $250 and 7 Payments of 142.85 =$1250
CTeen Jr. - 7th Grade                    Track 1 & Track 2
Member $250 and 7 Payments of 135.72 =$1200
Non member $250 and 7 Payments of 200.00 =$1650
PROGRAM & TUITION AGREEMENT:
I hereby confirm my child’s enrollment in The Chai Center Noskin Hebrew School.
I represent that I am the custodial parent or legal guardian of the child that I am enrolling and that the information I have provided is true and correct.
I fully understand that this enrollment, as part of my commitment to a long-term Jewish education at Noskin Hebrew School, is accepted only on the basis of the full year program, and agree to pay the full annual fees accordingly. I understand that no refunds or adjustments will be made for absences including, but not limited to, illness or vacation.
I agree to the following Mandatory Fees:
Track 1
$54 Student Activity Fee per family
$100 Security Fee per family
Track 2
$250 Material & Supplies Fee per child + Shipping
Signature of Parent or Legal Guardian*
Date*
MonthDayYear
PAYMENT OPTIONS:
Membership Status*
Chai Center MemberNon Member
Payment Plan*
PLAN A: Pay the entire amount in full at time of registrationPLAN B: Pay $250 non-refundable registration fee (towards tuition fee), Plus Mandatory Program Fees Today, Plus monthly payements*
* 7 post-dated checks from September through March (The checks should be dated for the 1st of every month) OR
7 Automatic monthly credit card payments on the 1st of the months: September through March

Payment

Credit Card Check

Postal / Zip Code

Country

Disclaimer
Accident: As the parent(s) or legal guardian of the above child/ren, I/we authorize any adult acting on behalf of Noskin 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, Noskin Hebrew School personnel will try, but are not required, to communicate with me prior to such treatment.
Trips and Outings: I hereby give permission for my child to attend and participate in all trips and outings organised as part of the program by The Chai Center Noskin Hebrew School.
Privacy: I hereby give permission for my child’s photographs/videos to be used in newsletters, local newspapers, The Chai Center and Noskin Hebrew School website or for promotion of our program.
Digital Signature of Parent or Legal Guardian*
Date*
MonthDayYear
Should be Empty:

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Hebrew School Registration 2020/2021

Parents

Emergency Contact Information

General Information

Tuition and Billing

Disclaimer