Hebrew School Registration 5781 - 2020/21
Enrollment Form
Student 1 - Last Name *
Student 1 - First Name *
Student 1 - Date of Birth *
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Student 1 - Grade in September 2020 *
Required
Student 1 - Does your child have any allergies or medical conditions that my impact your child during school hours? *
Student 1 - Does your child take medication regularly? If yes, please list. *
Student 1 - Does your child receive any special services in school, such as special education classes, resource room, or any other services? *
Student 2 - Last Name
Student 2 - First Name
Student 2 - Date of Birth
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/
DD
/
YYYY
Student 2 - Grade in September 2020
Clear selection
Student 2 - Does your child have any allergies or medical conditions that my impact your child during school hours?
Student 2 - Does your child take medication regularly? If yes, please list.
Student 2 - Does your child receive any special services in school, such as special education classes, resource room, or any other services?
Student 3 - Last Name
Student 3 - First Name
Student 3 - Date of Birth
MM
/
DD
/
YYYY
Student 3 - Grade in September 2020
Clear selection
Student 3 - Does your child have any allergies or medical conditions that my impact your child during school hours?
Student 3 - Does your child take medication regularly? If yes, please list.
Student 3 - Does your child receive any special services in school, such as special education classes, resource room, or any other services?
For All Students - Is there anything else about your child you would like us to know? Likes, dislikes, special interests, hobbies, areas of strengths to weakness, significant changes in school or home etc. Please list by student. *
For All Students: In the event of an emergency, do you authorize us to call your child's doctor, dentist, or an ambulance if needed? *
Siblings: Name and Age if NOT enrolled currently in Hebrew School *
Parent/Guardian 1 - Name: *
Parent/Guardian 1 - Cell Phone: *
Parent/Guardian 1 - Email Address: *
Parent/Guardian 2 - Name: *
Parent/Guardian 2 - Cell Phone: *
Parent/Guardian 2 - Email Address: *
Student's Address - Address/City/State: *
Fees
First Student - Grades 3-6: $1800
First Student - Grade 7: $3000 (Class and 1:1 Torah Lessons with Rabbi Jenn)
Additional Child/ren: $1000
Payment Information: I authorize Congregation Simchat HaLev to charge my credit card as indicated below. *
Check
Credit Card
Venmo - @simchathalev
Total School Balance for 2020/21
6 Monthly Installments
Credit Card Number
Credit Card Expiration Number
Credit Card Security Code
Submit
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