*Last Name
*First Name
*Hebrew Name
*Gender Male Female
*Date of Birth
*Address
*City
*Province
*Postal Code
*Country
*Home Phone
*Current School
*Grade (2023-24)
General Note
*Physician Name
*Physician Phone
Insurance
*Ohip Number
*Allergies
Medical Note
*Title --Select Title-- Dr. Mr.
Work Phone
*Cell Phone
*Email
*Title --Select Title-- Dr. Mrs. Ms.
*Marital Status --Select -- Married Divorced Separated
*Affiliation --Select -- Adath Israel Armour Heights Jewish Centre Beth David Beth Emeth Beth Jacob - Hamilton Beth Radom Beth Sholom Beth Tikvah Beth Torah Beth Tzedec Chabad on Bayview Chabad of Midtown Darchei Noam Forest Hill Jewish Centre Habonim Holy Blossom Kehillat Shaarei Torah Ledbury Jewish Centre - Chabad Magen David None Oraynu Cong. Other Petah Tikvah Shaarei Shomayim Shaarei Tefillah Temple Sinai Temple Emanuel Uptown Chabad Village Shul
Have there been adoptions or conversions in the family?
If yes, please explain
Name Phone # Relation
*Emergency 1
*Emergency 2
Emergency 3
Please choose enrollment options
2023-24 School Year: Sept. 2023 - June 2024
*Tuition --Select-- 2023-24 School Year
Total Amount:
These fees will only be charged upon acceptance of your child
Upon acceptance, a $500 non-refundable and non-transferable payment will be charged.
For credit card payments, a 3% fee will be added (aside for the deposit). If paying by cheque, upon acceptance, please drop off post dated cheques at our office to secure your child's spot.
*Card Type --Card Type-- Visa MC
*Card Number
*Expiration Date --Month-- 01 02 03 04 05 06 07 08 09 10 11 12 --Year-- 2023 2024 2025 2026 2027 2028 2029 2030 2031 2032 2033 2034 2035
*Security Code
Use Information above
*Name on Card
*Billing Address
*Billing Postal Code
As the parent(s) or legal guardian of the above child, I/we authorize any adult acting on behalf of Lamplighters Academy to hospitalize or secure treatment for my/our child, I/we further agree to pay all charges for that care and/or treatment. It is understood that if time and circumstances reasonably permit, Lamplighters Academy personnel will try, but are not required, to communicate with me/us prior to such treatment.
I agree to the terms and conditions above
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