Middot Registration Form
2017/2018
 

Student’s information

Name:

For additional child

Name:

 

Health, trip and picture waiver.
As the parent(s) or legal guardian of the above child, I/we authorize any adult acting on behalf of Chabad of West Orange County to hospitalize or secure treatment for my child in the event of a medical emergency, I further agree to pay all charges for that care and/or treatment. It is understood that if time and circumstances reasonably permit, Chabad of West Orange County personnel will try, but are not required, to communicate with me prior to such treatment.

I hereby give permission for my child to participate in all school activities, join in class and school trips on and beyond school properties

I allow my child to be photographed while participating in Chabad of West Orange County activities and that these pictures may be used for marketing purposes.

Parent initials:  


Date:

 

Tuition

Please check your choice for method of payment:

For one child

I will send a check for the full payment of $700

I will send four post-dated* payments of $175

Please charge my card for the full payment of $700

Please charge my card for four payments* of $175

 

For two children 
Includes 10% discount for additional child 

I will send a check for the full payment of $1,330 

I will send four post-dated* payments of $332.50

Please charge my card for the full payment of $1,330

Please charge my card for four payments* of $332.50

 

Card type: 

Card number: 

Expiration - Month:  Year: 

3 (for Amex 4) digit security code: 

*Sept 17 2017 
Nov. 1 2017
Jan 1 2018
March 1 2018

Please make checks payable to Chabad of West Orange County.