5775 / 2014-2015

Name of Child
Hebrew Name
Address
Grade
Age
Date of Birth
Previous Hebrew Education
Fathers Name
Address
Phone
Mobile
Mothers Name
Address
Phone
Mobile
Parent Email
Student Email

Is there any special medical or other information regarding your child we should be aware of?

Does you child have learning difficulties with general studies?   Yes  / No

Please explain

Emergency contact: Name
Number
Relationship

I hereby permit my child to participate in all JEC activities and join in trips on and beyond the program property. In case of emergency I hereby authorize the JEC Program to have my child taken care of by a physician in any way the situation may call for.

Tuition and fees: $300 for the entire school year, plus a $50 registration and book fee.

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Charge Amount
Card Type
Card Number
Expiration Date
Card Code