Weston/Westport Hebrew School Registration Form

Hebrew School Registration Form

Tuition payment must accompany this form. Annual tuition is $1,100. (payment options below)
Full Name *

First Name Last Name
Hebrew Name
Birth Date *

Month Day Year
Time of Birth

: Hour Minutes AM/PM Option
Grade *
Age *
School *
T-Shirt Size (child's)

Small Medium Large X-large
Second Child
Full Name

First Name Last Name
Hebrew Name
Birth Date

Month Day Year
Time of Birth

: Hour Minutes AM/PM Option
Grade
Age
School
T-Shirt Size (child's)

Small Medium Large X-large
Third Child
Full Name

First Name Last Name
Hebrew Name
Birth Date

Month Day Year
Time of Birth

: Hour Minutes AM/PM Option
Grade
Age
School
T-Shirt Size (child's)

Small Medium Large X-large
Home Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Phone Number *

Area Code Phone Number
Parent Information
Mother's name

First Name Last Name
Hebrew Name
Cell Phone

Area Code Phone Number
Work Phone

Area Code Phone Number
E-mail
Father's Name

First Name Last Name
Hebrew Name
Kohen Levi Israelite
Cell Phone

Area Code Phone Number
Work Phone

Area Code Phone Number
E-mail
Is the child’s natural mother Jewish? *

By Birth Conversion
If there were any adoptions or conversions in the family please explain
Does your child have any learning or behavior issues? If yes, please describe in detail and attach the school’s learning/behavior plan .
Medical and Emergency Information
Known allergies or medical/nutritional sensitivities? *
If parents cannot be reached in case of an emergency or illness, contact:
Name *

First Name Last Name
Phone Number *

Area Code Phone Number
Relationship to child:
Permission Agreement and Waiver
I hereby allow you to photograph/video my child/ren and use it for publicity or other projects *

Yes No
I hereby permit my child to participate in all School activities and to join in class and school trips on and beyond school properties and use any transportation selected by the Weston/Westport Hebrew School *
Initial Here
I give permission to the staff of Weston/Westport Hebrew School to take whatever emergency (i.e., first aid, disaster evacuation) measures as judged necessary for the care and protection of my child while under the supervision of Weston/Westport Hebrew School. *
Initial Here
I hereby give my permission to the physician selected by Weston/Westport Hebrew School to hospitalize and/or secure necessary treatment or anesthesia for my child, as named above in the event that I cannot be reached in an emergency. In case of medical emergency requiring immediate emergency care, I authorize the first responders to take my child to the nearest hospital, if necessary. *
Initial Here
Parent/ Guardian *
Print your name
Date *

Month Day Year
Parent/Guardian Signature *

Clear
Tuition Contract & Payment

Hebrew School Classes meet Tuesdays 4:00pm - 5:45pm. Tuition fees are non refundable. Should you decide to withdraw your child from WHS, your refund will be pro rated up to January 1. After that date no refund will be allowed for WHS tuition. There are no refunds or credits for days missed due to illness, holidays, or family vacations
*Bar/Bat Mitzvah tutoring & preparation are not included in school tuition.
Tuition *

$1,100
I hereby agree to pay tuition in the amount of $1,100 (non-refundable) *
Initial Here
Payment options: *

Check by mail : please download, print and mail form with payment Credit Card Payment in Full (fill out cc info at bottom of form) and Submit Charge my credit card monthly. Last payment is due in March. (fill out cc info. below) then fill out cc info. for your first payment at bottom of form and Submit
Please charge my card monthly in the amount of $
$ ( last payment in March)
Charge my card monthly: please add your CC#, exp. date and Security Code Below
I would like to contribute to the Hebrew School scholarship fund in the amount of $
$ Donation (tax deductible)
Philanthropic Leadership Circle

I Would like to join the philanthropic leadership circle that donates $360 to the Weston/Westport Hebrew School scholarship fund?

Please Charge my card now in the amount of *

USD $ Tuition/Donation

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Should be Empty:

Hebrew School Registration Form

Second Child

Third Child

Parent Information

Medical and Emergency Information

Permission Agreement and Waiver

Tuition Contract & Payment