Registration 2019- 2020

Father's Name

First NameLast Name

E-mail

Father's Mobile Number

Area CodePhone Number

Mother's Name

First NameLast Name

E-mail

Mother's Mobile Number

Area CodePhone Number

Home Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Student Name

First NameLast Name

Hebrew Name

Birth Date

MonthDayYear

Age

MaleFemale

Does your child read basic Hebrew

NoneSomewhatWell

Does your child speak/understand Hebrew?

NoneSomewhatWell

Does your child have previous Jewish education?

YesNo

If yes, please describe

Student Name

First NameLast Name

Hebrew Name

Birth Date

MonthDayYear

Age

MaleFemale

Does your child read basic Hebrew

NoneSomewhatWell

Does your child speak/understand Hebrew?

NoneSomewhatWell

Does your child have previous Jewish education?

YesNo

If yes, please describe

Student Name

First NameLast Name

Hebrew Name

Birth Date

MonthDayYear

Age

MaleFemale

Does your child read basic Hebrew

NoneSomewhatWell

Does your child speak/understand Hebrew?

NoneSomewhatWell

Does your child have previous Jewish education?

YesNo

If yes, please describe

Are the natural parents of the child(ren) Jewish

YesNo

Were there any conversions or adoptions in your family history

YesNo

If yes, please explain

What are the top 2 things you would like your child/ren to gain this year by coming to Pudong Hebrew School? If more than one child - please specify for each one:

Please mention any new and updated information that you feel we should know about your child/ren, or information that you think teachers should be aware of for this upcoming school year.

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.

AcceptDo Not Accept

Initial here:

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.

Discount:

5% Discount for students registered before August 12.

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.

Payment

Credit Card

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

Parent's Information

Student Information (Child 1)

Student Information (Child 2)

Student Information (Child 3)

General questions

Emergency Contact Information

Tuition Information