REGISTRATION FORM – 5785 (2024-2025)

Registration fee: $200

Registration payment information below.

"*" indicates required fields

Student Information

Name*

Legal First Name Last Name

Hebrew first and last name*

Nickname

Date of Birth*

Hebrew Day*

Month*

Year*

Address*

Street Address City State / Province / Region ZIP / Postal Code Country

Father's Information

Father's Name*

First Name Last Name

Father's Hebrew name*

Email address*

Cell Phone*

Home Phone*

Work Phone*

Occupation*

Mother's Information

Mother's Name*

First Name Last Name

Mother's Hebrew name*

Email address*

Cell Phone*

Home Phone*

Work Phone*

Occupation*

Schools Attended

5784 school info

School Attended*

Grade*

Primary Teacher*

Primary Teacher's Phone*

Additional Teacher (if applicable)

Additional Teacher's Phone

Principal*

Principal's Phone*

5783 school info

School Attended*

Grade*

Primary Teacher*

Primary Teacher's Phone*

Principal*

Principal's Phone*

Summer Program

5783 camp info

Name of Camp*

Name of Head Counselor*

Head Counselor's Phone*

Name of Counselor*

Counselor's Phone*

Name of Learning Teacher*

Learning Teacher's Phone*

Please describe any other information about your son (e.g. social, emotional, scholastic, etc., or any other issues/information you feel may be pertinent):

Payment

The registration fee is $200

Product Name

Payment Method*

American Express

MasterCard

Visa

Card Number 0000 0000 0000 0000 Expiration (mm/yyyy_ 01/2024 Security Code 000 Cardholder Name