ב"ה

Registration 2021/2022

Student Information
How many children are you registering?*Automatic 10% discount applied for 2nd and 3rd child
First ChildSecond ChildThird Child
First Child
New StudentRe-enrollment
Full Name*
First NameLast Name
Hebrew Name
First NameLast Name
Birth Date
MonthDayYear
School
Previous Jewish Education
Grade entering

Address*

Additional notable InformationPlease let us know if there are any allergies or other important information we need to be aware of.
Second Child
Full Name
First NameLast Name
Hebrew Name
First NameLast Name
Birth Date
MonthDayYear
School
Previous Jewish Education
Grade Entering
Additional notable InformationPlease let us know if there are any allergies or other important information we need to be aware of.
Third Child
Full Name
First NameLast Name
Hebrew Name
First NameLast Name
Birth Date
MonthDayYear
School
Previous Jewish Education
Grade Entering
Additional notable InformationPlease let us know if there are any allergies or other important information we need to be aware of.
Parents Information
Father's Name
First NameLast Name
Father's Hebrew Name
First NameLast Name
Father's Cell
Area CodePhone Number
Mother's Name
First NameLast Name
Mother's Hebrew Name
Mother's Cell
Area CodePhone Number
Is the natural mother of the child Jewish?
YesNo
Is the natural father of the child Jewish?
YesNo
If applicable, please descibe any conversions or adoptions in your family
Best way to send Hebrew School updates:
Cell PhoneEmailHandout
I am willing to assist in school activities, please contact me
Emergency Information
Emergency Contact
First NameLast Name
Relationship to child
Phone Number
Area CodePhone Number
Doctor's Name
First NameLast Name
Doctor's Telephone
Area CodePhone Number

Doctor's Address

Address

Accident, Privacy & Field Trip Declaration
Accident: As the parent(s) or legal guardian of [child(ren) listed], I/we authorize any adult acting on behalf of Danville Hebrew to hospitalize or secure treatment for my child, I further agree to pay all charges for that care and/or treatment. It is understood that if time and circumstances reasonably permit, Danville Hebrew personnel will try, but are not required to communicate with me prior to such treatment.
Trips & Outings: I hereby give permission for my child to attend and participate in all trips and outings organized as part of the program by Danville Hebrew.
Privacy: I hereby give permission for my child’s photographs/videos to be used for educational or promotional purposes, which include but are not limited to, brochures, Danville Hebrew website and Danville Hebrew social media. I understand that I can withdraw my consent at any time.
Signature of parent or legal guardian:
Date Signed
MonthDayYear
Additional Comments
Addditional Comments:
Payment
Please note: if you would like to pay tuition in 2 installments, please select the "Installments" option for payment. If you select "Credit Card" full tuition will be charged.
ReferralIf you were referred to Danville Hebrew or if you referred a family for the 2021/2022 school year, you will receive a $50 discount after checkout.
I Qualify
Total
$695.00

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Credit Card Installments

Postal / Zip Code

Country

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