Student Information

*Last Name

*First Name

*Hebrew Name

*Gender

Date of Birth

*Address

*City

*Province

*Postal code

*Home Phone

Previous School

Group Child with (no guarantees)

Medical Information

*Physician Name

*Physician Phone

Insurance

*Ohip Number

*Allergies

Medical Note

Parent Information
Father

*Title

*First Name

*Last Name

*Work Phone

*Cell Phone

*Email

Mother

*Title

*First Name

*Last Name

Work Phone

*Cell Phone

*Email

*Marital Status

*Affiliation

Have there been adoptions or conversions in the family?

If yes, please explain

Emergency Information

Name Phone # Relation

*Emergency 1

*Emergency 2

Enrollment Options / Tuition & Fees

Please choose enrollment options

Sessions


*Tuition


Total Amount:

$595 deposit charged now. The balance in 6 payments on: Jan 1, March 1, May 1, Jul 1, Sept 1, Dec 1, 2020

Payment Information

For credit card payments, a 3% fee will be added. If paying by cheque, please drop off the deposit and post dated cheques at our office to secure your child's spot.

.

Card Type

Card Number

Expiration Date

Security Code

Use Information above

Name on Card

Billing Address

Billing Zip code

I agree to the terms and conditions above

secure