Registration Form & Payment

How many students would you like to register?*

Student #1 - Name*

First Last

Student #1 - Grade*

Student #1 - Hebrew Name*

Student #1 - Public School Grade*

Student #1 - Date of Birth*

Student #2 - Name

First Last

Student #2 - Grade

Student #2 - Hebrew Name

Student #2 - Public School Grade

Student #2 - Date of Birth

Student #3 - Name

First Last

Student #3 - Grade

Student #3 - Hebrew Name

Student #3 - Public School Grade

Student #3 - Date of Birth

Student #4 - Name

First Last

Student #4 - Grade

Student #4 - Hebrew Name

Student #4 - Public School Grade

Student #4 - Date of Birth

Parent Information

Parent #1 - Name

Parent #2 - Name

Parent #1 - Cell Phone

Parent #2 - Cell Phone

Parent #1 - Work Phone

Parent #2 - Work Phone

Parent #1 - Email

Parent #2 - Email

If parents are divorced or separated, who is the custodial parent?

What is the best way to reach you during school hours, if needed?

Cell phone
Work phone
Email

Emergency Contacts

In the event parents are unable to be contacted in case of illness or emergency, the following persons are to be notified:

Emergency Contact #1 - Name*

Emergency Contact #2 - Name

Emergency Contact #1 - Cell Phone*

Emergency Contact #2 - Cell Phone

Medical Information

Does one of the students have any allergies or medical conditions that we should be aware of?*

Yes
No

If yes, who?

If yes, please describe:

Does any member of your family have any allergies or medical conditions that could be put at risk because of food or any school activity?*

Yes
No

If yes, who?

If yes, please describe:

Hospital/Emergency Room preference

Call an ambulance?

Yes
No

Health Plan

Insurance Number

Payment Information

Payment Method*

Pay by credit card
Pay by check

Please make your check payable to the synagogue and mail it to the synagogue office with a copy of the email receipt you will receive upon submission.

Please note that upon submission, you will be taken to PayPal's website in order to enter your credit card information.

Would you like to add an amount to cover the credit card convenience fee?

Yes - let me add a 2.2% + .30 contribution

Additional contribution to cover the credit card convenience fee

Price: $0.00

Total

$0.00

Billing Information

Billing Name*

First Last

Billing Address*

Street Address City State ZIP Code

Billing Phone*

Billing Email*

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Registration Form & Payment

Parent Information

Emergency Contacts

Medical Information

Payment Information

Billing Information

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