Registration

PAYMENT INFORMATION

•Tuition for Sept 2019-June 2020 is $875 * per child. Book fees are included.

•A tax deductible donation receipt will be issued for the full amount.

*This includes $250 registration and book fee which is non-refundable.

Location*

Dublin Heights (Wednesdays 3:00-5:00pm)Faywood ABC (Mondays 3:15-5:15pm)Wilmington (Tuesdays 3:15-5:15pm)

Student's Full Name*

First NameLast Name

Home Address*

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

Hebrew Name*

Home Phone Number*

Area CodePhone Number

Gender*

FemaleMale

Birth Date*

MonthDayYear

Allergy or Health Information

Does your child's allergies require the use of an Epi Pen?

YesNo

Does your child have any learning or behavioral challenges?

YesNo

If yes, please specify.

Age (as of Sep 1, 2019)*

Grade (as of Sep 1, 2019):*

Has your child attended Hebrew School in the past?*

YesNo

Does your child read basic Hebrew?*

YesNo

If Yes, How well?

Hebrew Immersion option for Grades 3-6(only available at Dublin and Faywood)

YesNo

Would you be interested in a Bar/Bat Mitzvah Program outside of regular programming?

YesNo

Which school does your child attend?*

Parent's Marital Status*

Father's Name*

PrefixFirst NameLast Name

Father's E-mail*

Father's Cell Phone*

Area CodePhone Number

Father's Work Phone

Area CodePhone Number

Mother's Name*

PrefixFirst NameLast Name

Mother's E-mail*

Mother's Cell Phone*

Area CodePhone Number

Mother's Work Phone

Area CodePhone Number

Is the natural mother of the child Jewish?*

YesNo

Were there any Jewish Conversions in your family?*

YesNo

If yes, please provide details:

Were there any adoptions in your family?*

YesNo

Does your family have membership with a Synagogue?*

YesNo

If yes, please specify:

# 1 Full Name

First NameLast Name

Phone Number

Area CodePhone Number

Address

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

Relationship to Child*

#2 Full Name

First NameLast Name

Phone Number

Area CodePhone Number

Address

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

Relationship to Child*

Child will not be released to any individual not in this section unless otherwise indicated in writing by parents/guardian.

Total : $875

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

Comments

Student Information

Parent Information

Authorizations for Pick-Up

Payment Information