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The Aleph Art Room

Hebrew School Reimagined
Inspiring Judaism through the language of the arts

ב"ה

Register

Please feel free to call Mrs. Mushka Deitsch with any questions while filling out this form: 914-458-2441
Parent Information
Father's Name*

First Name Last Name
Father's E-mail
Father's Cell

Area Code Phone Number
Mother's Name*

First Name Last Name
Mother's Hebrew Name
Mother's Email
Mother's Cell

Area Code Phone Number

Address*

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

Child Information:
Student 1 Name:*

First Name Last Name
Hebrew Name:
Birthdate:*

Month Day Year
Age:*
Grade Entering:*
Previous Jewish Education

YesNo
If yes - where?
Student 2 Name:

First Name Last Name
Birthdate:

Month Day Year
Age:
Grade Entering:
Previous Jewish Education

YesNo
If yes - where?
Is the natural mother of the Child(ren) Jewish?*

YesNo
Were there any conversions or adoptions in the family?*

YesNo
If yes, please explain
Comments/Notes
Medical Information

Persons to be contacted in case of an emergency when parents cannot be reached: (Please provide at least two contacts)
Emergency Contact

First Name Last Name
Relationship to child(ren)
Phone Number

Area Code Phone Number
Family Physician

First Name Last Name
Physician Phone
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.
As the parent(s) or legal guardian of the above child, I/we authorize any adult acting on behalf of Chabad Jewish Center Aleph Art Room program 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, Chabad Jewish Center Aleph Art Room program personnel will try, but are not required, to communicate with me prior to such treatment. I hereby give permission for my child to participate in all program activities, join in class and school trips on and beyond the program properties and allow my child to be photographed while participating in Chabad Jewish Center Aleph Art Room activities and that these pictures may be used for marketing purposes.
*

I agree
Name*
Initials*
Registration & Tuition Information:
Times:
Wednesday 5:00 pm - 6:30 pm for the duration of the scholastic year.

Tuition:
$1050 - full year
--
$100 sibling discount
$100 security fee

Contact Rabbi Sruli Deitsch 914.458.2441 to inquire about scholorships.
Registration:*

1 Child: Pay in Full - $10501 Child: Pay in 3 Installments - $3502 Children with sibling discount: Pay in full - $20002 Children with sibling discount: Pay in 3 Installments - $666
Registration:

SecurityPay in 3 Installments - $316.66Pay in full with sibling discount - $900Pay in 3 Installments with sibling discount - $300
I would like to register student 1 for:
I would like to register student 2 for: $50 sibling discount
I would like to contribute to the Scholarship Fund:

$180
Payment Information:
Total due today including $100 security fee:

$100.00

Payment*

Credit Card

We accept Visa, MasterCard, American Express, Discover
Credit Card Number
Expiration Month	Expiration Year

Should be Empty:

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Educate Your Child... Educate a Generation

Please feel free to call Mrs. Mushka Deitsch with any questions while filling out this form: 914-458-2441

Parent Information

Child Information:

Medical Information

Registration & Tuition Information:

Payment Information: