Congregation Beth Israel

Please note that fields indicated by red text are required to be completed.

Student's Information:

First Name

Last Name

Male
Female

Child's Hebrew Name

Birth date
/ /

Student's Email

Grade in Sept.

Secular/Day School

District

Special learning / medical needs, medication lists and any other information we should have concerning your child:

Parent's Information:

First Parent's Name

Second Parent's Name

Address

City

State

Zip

City

State

Zip

Home Phone

Work Phone

Cell Phone

If parents divorced or separated with whom does child reside?

Do you want all mailings from the Religious School to be sent to both parents?

Emergency Contacts :

Primary Contact Name

Primary Contact Phone

Secondary Contact Name

Secondary Contact Phone

Yes, my child has permission to participate in all class field trips during the 2008-2009 school year. I/we understand that I/we will be notified in advance of all trips. I/we will notify the school in writing if my child is unable to participate.

Yes, in the event that I/we cannot be reached in an emergency, I/we authorize the Congregation Beth Israel to seek medical attention for my child.

Tuition for 7th – 12th grade is $330. Please make your payment in full by clicking the “Pay Now” button. 7th graders enrolled in Midweek Hebrew and whose Bar/Bat Mitzvah falls after February 1, 2009 require an additional $150 fee.

Amount Due:	$330 – 7th – 12th Grade without Midweek Hebrew
	$480 – 7th Grade with Midweek Hebrew

After completing the PayPal payment process,
you will be returned to the Main Page in order to register additional children.