Middot Registration Form
2017/2018

Student’s information

Name:

Hebrew name:

Male Female

Date of Birth: Month:
Day: Year:

Age as of 09/17:

Grade as of 09/17:

School:

Prior Jewish/Hebrew education (if any):
Does your child read Hebrew?

Does your child have any learning difficulties? If yes, please describe:

For additional child

Name:

Hebrew name:

Male Female

Date of Birth: Month:
Day: Year:

Age as of 09/17:

Grade as of 09/17:

School:

Prior Hebrew education (if any):

Does your child read Hebrew?

Does your child have any learning difficulties?

If yes, please describe:

Family Information

Address:

City: CA

Zip Code:

Telephone:

Father’s Information:

Name:

Cell:

Email:


Mother’s Information:

Name:

Cell:

Email:

Were there any conversions and/or adoptions in the family?

 

If yes, please describe:

Are the natural parents of the child/ren Jewish?
Father:
Mother:

Medical Information

Any medical conditions/allergies or related regarding your child we should be aware of?

Person to be contacted in case of an emergency:

Name:

Phone:

Relationship to child:

 

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.

Comments: