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DHS Registration

Please complete this form as an initial registration for Discovery Hebrew School
CONTACT:
Number of Children Being Registered:*
Child Name:*
First Name Last Name
Jewish Name:*
Date of Birth:*

Month Day Year
Gender:*
School Currently Attending:*
Hebrew Reading Proficiency:*

NoneSomewhatWell
Previous Jewish Education:*

YesNo
Where?
Any considerations, such as learning disorder or difficulty, the school should be aware of? (Confidential)*
Child 2 Name:
Child 2 Jewish Name:
Child 2 Birth Date:

Month Day Year
Child 2 Gender:
Child 2 School Currently Attending:
Child 2 Hebrew Reading Proficiency:

NoneSomewhatWell
Child 2 Previous Jewish Education:

YesNo
Where?
Child 2: Any considerations, such as learning disorder or difficulty, the school should be aware of? (Confidential)
Child 3 Name:
Child 3 Jewish Name:
Child 3 Birth Date:

Month Day Year
Child 3 Gender:
Child 3 School Currently Attending:
Child 3 Hebrew Reading Proficiency:

NoneSomewhatWell
Child 3 Previous Jewish Education:

YesNo
Where?
Child 3: Any considerations, such as learning disorder or difficulty, the school should be aware of? (Confidential)
Were there any conversions or adoptions in your family? *

YesNo
If yes, please describe: (Confidential)*
Is the Mother of the Child/ren Jewish?*

YesNo
Is the Father of the Child/ren Jewish?*

YesNo
PARENTS:
Mother's Info
Mother's Full Name:*
First Name Last Name
Mother's Occupation:*
Mother's Cell Phone Number:*

Area Code Phone Number
Mother's E-mail:*
Father's Info
Father's Full Name*
First Name Last Name
Father's Occupation:*
Father's Cell Phone Number:*

Area Code Phone Number
Father's E-mail*

Address:*

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

Would you be interested in Hebrew School Family Programming?*

Yes, Please!Maybe sometimesNah, not for us
How often?*

Once a monthEvery 6 weeksEvery Other MonthTwice a Year
What kinds of Family Programming would you be interested in?*

At a parkAt JDCAt a parent's houseAny other venues.
PAYMENT INFORMATION
Registration Fee: $50/student Pay in Full: $895/Child Early Bird: $795/Child
Current Date

Month Day Year
at Hour Minutes
Payment Options:* Early Bird before July 1

1 Child Full Payment $7952 Children Full Payment $15903 Children Full Payment $2385Just Pay Registration Fee
Payment Options:*

1 Child Full Payment $8952 Children Full Payment $17903 Children Full Payment $2685Just Pay Registration Fee
Donation: I'd like to give a student in need a chance to receive a Hebrew School education

$54.00$90.00$180.00$360.00$650.00
Total:

$0.00
Yes, I'd like to donate the cost of processing this transaction by adding 3%

Payment:

Credit Card

We accept Visa, MasterCard, American Express, Discover
Credit Card Number	Security Code
Name on Card
Expiration Month	Expiration Year

Billing Address

Street Address

City

State / Province

Postal / Zip Code

Country

We will contact you soon to discuss your family's learning goals.

Looking forward to a wonderful year of learning and growth!
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CONTACT:

PARENTS:

PAYMENT INFORMATION