Parent's InformationFather's NameFirst NameLast NameE-mailFather's Mobile NumberArea CodePhone NumberMother's NameFirst NameLast NameE-mailMother's Mobile NumberArea CodePhone NumberHome AddressStreet AddressStreet Address Line 2CityState / ProvincePostal / Zip CodePlease SelectUnited StatesAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanThe BahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChilePeople's Republic of ChinaRepublic of ChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCook IslandsCosta RicaCote d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonThe GambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNagorno-KarabakhNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandTurkish Republic of Northern CyprusNorthern MarianaNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint BarthelemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSomalilandSouth AfricaSouth OssetiaSpainSri LankaSudanSurinameSvalbardSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTransnistria PridnestrovieTrinidad and TobagoTristan da CunhaTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamBritish Virgin IslandsUS Virgin IslandsWallis and FutunaWestern SaharaYemenZambiaZimbabweOtherCountryStudent Information (Child 1)Student NameFirst NameLast NameHebrew NameBirth Date1 - January2 - February3 - March4 - April5 - May6 - June7 - July8 - August9 - September10 - October11 - November12 - DecemberMonth12345678910111213141516171819202122232425262728293031Day2019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920YearAgeMaleFemaleDoes your child read basic HebrewNoneSomewhatWellDoes your child speak/understand Hebrew?NoneSomewhatWellDoes your child have previous Jewish education?YesNoIf yes, please describeStudent Information (Child 2)Student NameFirst NameLast NameHebrew NameBirth Date1 - January2 - February3 - March4 - April5 - May6 - June7 - July8 - August9 - September10 - October11 - November12 - DecemberMonth12345678910111213141516171819202122232425262728293031Day2019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920YearAgeMaleFemaleDoes your child read basic HebrewNoneSomewhatWellDoes your child speak/understand Hebrew?NoneSomewhatWellDoes your child have previous Jewish education?YesNoIf yes, please describeStudent Information (Child 3)Student NameFirst NameLast NameHebrew NameBirth Date1 - January2 - February3 - March4 - April5 - May6 - June7 - July8 - August9 - September10 - October11 - November12 - DecemberMonth12345678910111213141516171819202122232425262728293031Day2019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920YearAgeMaleFemaleDoes your child read basic HebrewNoneSomewhatWellDoes your child speak/understand Hebrew?NoneSomewhatWellDoes your child have previous Jewish education?YesNoIf yes, please describeGeneral questionsAre the natural parents of the child(ren) JewishYesNoWere there any conversions or adoptions in your family historyYesNoIf yes, please explainWhat 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.Emergency Contact InformationPlease list two contacts to be used in case of emergencies (other than your home and business numbers). Emergency Contact 1First NameLast NamePhone NumberArea CodePhone NumberRelationship to childEmergency Contact 2First NameLast NamePhone NumberArea CodePhone NumberRelationship to childChild's physician or medical facilityFirst NameLast NamePhone NumberArea CodePhone NumberCONFIDENTIAL: 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 AcceptInitial here:Tuition InformationThe 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 PlansBill 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.PaymentCredit CardVisaMasterCardAmerican ExpressDiscoverCredit Card TypeCredit Card NumberSecurity CodeName on Card1 - January2 - February3 - March4 - April5 - May6 - June7 - July8 - August9 - September10 - October11 - November12 - DecemberExpiration Month2019202020212022202320242025202620272028Expiration YearShould be Empty: Submit This page uses TLS encryption to keep your data secure.