Name
*
First Name
Last Name
Hebrew Name
First Name
Last Name
Date of Birth
*
MM
DD
YYYY
What time was your child born
Hour
Minute
Second
AM
PM
School (September 2024)
Grade (September 2024)
Past Jewish studies lesson
Home Address of child:
Child lives with:
Cultural Background:
Language used at home:
Is the natural mother of the child Jewish
If there any conversion or adoption in your family? If yes, please describe:
PARENTS OF CHILD - MOTHER
Title:
Surname:
Given Name:
Hebrew Name:
Occupation:
Home Address:
Home Telephone:
(###)
###
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Cell phone:
(###)
###
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Email:
Country of Birth:
Main Language:
Synagogue Affiliation:
PARENT OF CHILD - FATHER
Title:
Surname:
Given Name:
Hebrew Name:
Occupation:
Home Address:
Home Telephone:
(###)
###
####
Cell Phone:
(###)
###
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Email:
Country of Birth:
Main Language:
Synagogue Affiliation:
Main Expectation:
Marital Status:
Main email correspondence:
Primary mail correspondence:
MEDICAL & SPECIAL NEEDS DETAILS
Is your child taking permanent medication? If yes, please spesify
Any known allergies(incl. reaction to medication)and any present medical conditions? Specify
Does your child require the use of an epi-pen?
Is your child gluten-free? Please list 2 snacks your child will enjoy:
EMERGENCY INFORMATION
Emergancy Contact:
Relationship to child:
Home Telephone:
(###)
###
####
Cell phone:
(###)
###
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Doctors Name:
Doctor's Telephone:
(###)
###
####
Doctor's Address:
OTHER PERSON AUTHORIZED TO PICK-UP CHILD
Name:
Relationship to child:
Cell phone:
(###)
###
####
Address:
ACCIDENT, FIELD TRIP & PRIVACY DECLARATION
ACCIDENT: As the parent(s) of __________________ , I/we authorize any adult acting on behalf of Village Synagogue to hospitalize or seure treatment for my child, I further agree topay all charges for that care and/or treatment. It is understood that if time and circumstances reasonably permit, Village Synagogue personal 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 Village Synagogue.
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, Village website and Village social media. I understand that I can withdraw my consent at any time.
Signature of parent or legal guardian
*
I fully understand that this application is accepted only on the basis of the full year program including the Batmitzvah Shabbaton and Ceremony, and agree to pay the full annual fees accordingly. I authorize Bat-Mitzvah Academy to charge my credit card accordingly.
*
Signature of parent or legal guardian *
*
A non-refundable deposit of $100 per child is needed to secure your child’s spot in the Bat Mitzvah Academy
*
I will be paying tuition in full by September 1st, 2023
I will be paying tuition in 2 payments. Payment #1 will be charged on September 1, 2023. Payment #2 will be charged on December 1, 2023
I will be paying tuition in 4 payments on: September 20, 2023, November 20, 2023, December 20, 2023, February 20, 2024
Card Number
*
Name on card
*
Security Code
*
Signature
*
Billing Zip Code
*
Billing Address
*
Signature of parent or legal guardian
*
Date
*
MM
DD
YYYY
