RETURNING STUDENT FORM Student Name * First Name Last Name Hebrew Name * Date of Birth * MM DD YYYY What time was your child born * Hour Minute Second AM PM School Entering (September 2023) * Grade Entering (September 2023) * * Kindergarten 1st 2nd 3rd 4th 5th 6th 7th My mailing address and email address remain the same Yes/No If No, please describe * MEDICAL & SPECIAL NEEDS DETAILS Is your child taking permanent medication? If yes, please specify * No Yes Any known allergies(incl. reaction to medication)and any present medical conditions? Specify * No Yes Allergies Nut allergy Asthma Anaphylaxis Other Does your child require the use of an epi-pen? * Is your child gluten-free? Please list 2 snacks your child will enjoy: * Emergency Contact: * First and Last Name Relationship to child: * Emergency contact Cell phone: * Country (###) ### #### Doctors Name: * Doctor's Telephone: * Country (###) ### #### Doctor's Address: * OTHER PERSON AUTHORIZED TO PICK-UP CHILD * NAME Relationship to child: * Cell phone: * Country (###) ### #### Address: * ACCIDENT, FIELD TRIP & PRIVACY DECLARATION ACCIDENT: As the parent(s) , I/we authorize any adult acting on behalf of Village Hebrew 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, Village Hebrew personnel 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 Hebrew. 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 * TUITION - September 2023-MAY 2024 - $1095 ● Tuition fee covers all weekly programs, both Hebrew language & Jewish heritage studies, snacks & drinks. ● There is a 10% tuition discount for a second sibling ● There is a $100 tuition credit per family if you refer another family to Village Hebrew ● A non-refundable deposit of $100 per child is needed to secure your child’s spot in Village Hebrew. This will be taken off the sum of your tuition. A non-refundable deposit of $100 per child is needed to secure your child’s spot in Village Hebrew. This will be taken off the sum of your tuition. * I will be paying tuition by September 1st, 2023 I will be paying tuition in 2 payments: September 1st, 2023 & December 1, 2023 I will be paying tuition in 8 monthly payments from September 20th 2023 to April 20, 2024 CREDIT CARD INFORMATION Visa / Mastercard / American / Express Card Number * Name on card: * Expiration: * MM/YEAR Security Code: * Signature: * Billing Zip Code: * Billing Address: * PROGRAM & TUITION DECLARATION I confirm my child’s enrollment in Village Hebrew’s afternoon school. I represent that I am the custodial parent or legal guardian of the child that I am enrolling and that the information I have provided is true and correct. I agree to Village Hebrew’s terms and conditions as outlined in the Parent Handbook (emailed to parents). I fully understand that this enrollment, as part of my commitment to a long-term Jewish education at Village Hebrew, is accepted only on the basis of the full-year program, and agree to pay the full annual fees accordingly. I understand that no refunds or adjustments will be made for absences including, but not limited, to illness or vacation. Signature of parent or legal guardian: * Date: * MM DD YYYY Thank you for submitting your enrollment to Village Hebrew!