Talmud Torah Registration


    1st child

    Full Name of Child:

    Hebrew Name:

    Date of Birth:

    Grade in September 2021:

    Food Allergies:

    Special Needs/IEP/Classification/Medication:

    2nd child

    Full Name of Child:

    Hebrew Name:

    Date of Birth:

    Grade in September 2021:

    Food Allergies:

    Special Needs/IEP/Classification/Medication:

    3rd child

    Full Name of Child:

    Hebrew Name:

    Date of Birth:

    Grade in September 2021:

    Food Allergies:

    Special Needs/IEP/Classification/Medication:

    4th child

    Full Name of Child:

    Hebrew Name:

    Date of Birth:

    Grade in September 2021:

    Food Allergies:

    Special Needs/IEP/Classification/Medication:

    Parent Info

    Father's Name:

    Mother's Name:

    Home Address:

    Home Telephone #:

    Mother's Cell #:

    Father's Cell #:

    Mother's Email:

    Father's Email:

    Physician's Name:

    Physician's Telephone #:

    Additional Emergency Contact Person:

    Emergency Contact Telephone #:

    Credit Card Information

    Credit Card #:
    If not paying by credit card, leave blank

    CVV:

    Expiration Date:

    Billing Zip Code:

    Amount:

    Installment #1:

    Installment #2:

    Installment #3:

    Installment #4:

    Credit Card Payments are accepted with a 4% charge for each transaction.

    Parents' Authorization

    In the event of an emergency, I give permission to obtain any and all appropriate medical treatment as may be necessary for the welfare of the children named above.

    Father's Signature:

    Mother's Signature:

    Date:

    Additional Notes: