Student Profile
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First Name |
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Last Name |
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Hebrew Name |
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DOB |
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School |
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Grade Entering |
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Hebrew Reading Proficiency |
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Previous Jewish Education |
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Where? |
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Parent Information
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Father's Name |
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Phone |
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Mother's Name |
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Phone |
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Address |
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City |
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State |
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Zip |
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Email Address |
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Emergency Information
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Emergency Contact 1 |
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Phone |
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Emergency Contact 2 |
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Phone |
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Doctor |
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Address |
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Phone |
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CONFIDENTIAL: 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. |
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Payment Information |
Private Hebrew Tutoring
Full Payment $1500 | Monthly Payment $150 |
Please select: |
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Please consider an added donation to our scholarship fund
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Total Amount to be charged today: |
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Credit Card Number |
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CVV |
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Expiration Date |
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As always, no child will be turned away due to lack of funds! Scholarships available.
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Authorization
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Transport / Emergency Care as listed above Authorization |
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Media Authorization |
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