Re-Registration 2019 - 2020 - Chabad of Pudong

Parent Name
First NameLast Name

Address (if different from last year)

Street Address

City
Postal / Zip Code	Country

Student Information (Child 1)
Student Name
First NameLast Name
Age:
Student Information (Child 2)
Student Name
First NameLast Name
Age:
Student Information (Child 3)
Student Name
First NameLast Name
Age:
Emergency Contact Information
Please list two contacts to be used in case of emergencies (other than your home and business numbers).
Emergency Contact 1
First NameLast Name
Phone Number
Area CodePhone Number
Relationship to child
Emergency Contact 2
First NameLast Name
Phone Number
Area CodePhone Number
Relationship to child
Child's physician or medical facility
First NameLast Name
Phone Number
Area CodePhone Number
CONFIDENTIAL: Does your child have any allergies or other medical condition we should be aware of? If yes, please describe them and indicate special precautions or care needed.
As the parent(s) or legal guardian of the Children above, I/we authorize any adult acting on behalf of Pudong Hebrew School 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, Pudong Hebrew School personnel will try, but are not required, to communicate with me prior to such treatment. I hereby give permission for my child to attend all field trips and outings with Pudong Hebrew School.
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Initial here:
Tuition Information
The following is a tuition agreement for the Pudong Hebrew School. A full payment plan must be submitted to the school office before the school year begins. No child will be turned away for lack of funds.
Tuition fee:
Pudong Hebrew School: ¥5,100 + ¥250 registration & book fee. Includes Registration, Supplies, Snack & Yearly Hebrew School family Shabbat dinner.

Payment

Credit Card

Credit Card Type
Credit Card Number	Security Code
Name on Card
Expiration Month	Expiration Year

Billing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Payment Plans
Bill me the full payment of ¥5,100 + ¥250 through the credit card given below.I would like to pay the tuition in 5 instalments through the year. Charge my credit card 5 times ¥1,070 of the overall tuition every month, September through January.I will pay the full payment of ¥5,100 + ¥250 cash, before the beginning of the school year.
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Student Information (Child 1)

Student Information (Child 2)

Student Information (Child 3)

Emergency Contact Information

Tuition Information