Hebrew School Registration 2024/2025 CHILD'S INFO: Full Name* First Name Last Name Hebrew Name Gender* MaleFemale Birth Date* 1 - January2 - February3 - March4 - April5 - May6 - June7 - July8 - August9 - September10 - October11 - November12 - December Month12345678910111213141516171819202122232425262728293031 Day202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 Year Time of Birth 123456789101112 Hour001020304050 MinutesAMPM School Attending* 2024/2025 Grade* 2024/2025 Past Hebrew Lessons* No Previous HSPrivate Tutor Please choose a program:* Grades K-7: Sunday morning Register another child? YesNo CHILD 2: Full Name First Name Last Name Hebrew Name Gender MaleFemale Birth Date 1 - January2 - February3 - March4 - April5 - May6 - June7 - July8 - August9 - September10 - October11 - November12 - December Month12345678910111213141516171819202122232425262728293031 Day202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 Year Time of Birth 123456789101112 Hour001020304050 MinutesAMPM School Attending 2024/2025 Grade 2024/2025 Past Hebrew Lessons No Previous HSPrivate Tutor Please choose a program:* Grades K-7: Sunday morning Parents Parent's Marital Status* MarriedSeparatedDivorcedFather DeceasedMother DeceasedSingle Parent 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* Dr.Mr.Mrs.Ms. Parent 1 Full Name* First Name Last Name E-mail* Work Phone* Area Code Phone Number Cell Phone* Area Code Phone Number Occupation* PARENT 2: Parent 2 Title Dr.Mr.Mrs.Ms. Parent 2 Full Name First Name Last Name E-mail Work Phone Area Code Phone Number Cell Phone Area Code Phone Number Occupation HOME: Home Address* Street Address Street Address Line 2 City State / Province Postal / Zip CodePlease SelectUnited StatesAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanThe BahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChilePeople's Republic of ChinaRepublic of ChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCook IslandsCosta RicaCote d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonThe GambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern MarianaNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint BarthelemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSomalilandSouth AfricaSouth OssetiaSpainSri LankaSudanSurinameSvalbardSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTristan da CunhaTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamBritish Virgin IslandsUS Virgin IslandsWallis and FutunaWestern SaharaYemenZambiaZimbabweOther Country Home Phone Area Code Phone Number Emergency Contact Information EMERGENCY CONTACT: Full Name* First Name Last Name Phone Number* Area Code Phone 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 Code Phone Number Address* General Information OTHER PERSON AUTHORIZED TO PICK UP CHILD: Name of Authorized Person First Name Last Name Cell Phone of Authorized Person Area Code Phone 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-7th Grade Member $250 and 4 Payments of $187.50 = $1,000 Non member $250 and 4 Payments of $250 = $1,250 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, due at registration:$54 Student Activity Fee per family$100 Security Fee per family Signature of Parent or Legal Guardian* Date* Month Day Year PAYMENT OPTIONS: Membership Status* Chai Center MemberNon Member Payment Plan* PLAN A: Pay the entire amount in full, including fees, at time of registrationPLAN B: Pay $250 non-refundable registration fee (towards tuition fee), Plus Mandatory Program Fees Today, Plus monthly payments* * 4 Automatic monthly credit card payments on the 1st of the months: September through December Payment* Credit Card We accept Visa, MasterCard, American Express, Discover Credit Card Number Security Code Name on Card1 - January2 - February3 - March4 - April5 - May6 - June7 - July8 - August9 - September10 - October11 - November12 - December Expiration Month2024202520262027202820292030203120322033 Expiration YearBilling Address Street Address City State / Province Postal / Zip CodePlease SelectUnited StatesAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanThe BahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChilePeople's Republic of ChinaRepublic of ChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCook IslandsCosta RicaCote d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonThe GambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern MarianaNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint BarthelemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSomalilandSouth AfricaSouth OssetiaSpainSri LankaSudanSurinameSvalbardSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTristan da CunhaTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamBritish Virgin IslandsUS Virgin IslandsWallis and FutunaWestern SaharaYemenZambiaZimbabweOther 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* Month Day Year Submit Should be Empty: This page uses TLS encryption to keep your data secure.
This page uses TLS encryption to keep your data secure.
This page uses TLS encryption to keep your data secure.
This page uses TLS encryption to keep your data secure.