Hebrew School Registration Form

Thank you for registering your children in our Hebrew school. We look forward to seeing them in the fall.

In order to enroll your children in the UVJC religious school, you must be a member in good standing at the UVJC. Please do not hesitate to contact our treasurer at treasurer@uvjc.org for special abatements or scholarships if you are in financial need. The UVJC does not turn anyone away for financial reasons.

I accept the policy that I must join the UVJC or renew my membership this year in order to enroll my children in Hebrew school.

First (Eldest) Child's Information

Name (Child 1)*

First Last Hebrew

Date of birth (Child 1)*

Gender (Child 1)*

Grade level (Child 1)*

Education information (Child 1)*

Please describe your child's learning style and provide any tips you have to help the teacher succeed in working with your child. We can develop a more positive learning environment for your child when we know, in advance, if s/he has an IEP or 504 plan in regular school. Please let us know this so that we can discuss with you which details, if any, it is appropriate to share with the classroom teacher. Thanks!

Physician's Name (Child 1)*

Physician's Phone Number*

Allergies/Special Health Considerations (Child 1)*

Medication authorization (Child 1)

I authorize the UVJC to administer medications that I have supplied for medical conditions noted above. I have supplied the following medications to the Director of Education, and instructions are attached to the medications supplied.

Tuition (Child 1)*

Would you like to register a second child?*

Yes
No

Second Child's Information

Second Child's Name

First Last Hebrew

Date of birth (Child 2)

Gender (Child 2)

Grade level (Child 2)

Education information (Child 2)

Please describe your child's learning style and provide any tips you have to help the teacher succeed in working with your child. We can develop a more positive learning environment for your child when we know, in advance, if s/he has an IEP or 504 plan in regular school. Please let us know this so that we can discuss with you which details, if any, it is appropriate to share with the classroom teacher. Thanks!

Physician's Name (Child 2)

Allergies/Special Health Considerations (Child 2)

Medication authorization (Child 2)

I authorize the UVJC to administer medications that I have supplied for medical conditions noted above. I have supplied the following medications to the Director of Education, and instructions are attached to the medications supplied.

Tuition (Child 2)

Would you like to register a third child?

Yes
No

Third Child's Information

Name (Child 3)

First Last Hebrew

Date of Birth (Child 3)

Gender (Child 3)

Grade level (Child 3)

Education information (Child 3)*

Please describe your child's learning style and provide any tips you have to help the teacher succeed in working with your child. We can develop a more positive learning environment for your child when we know, in advance, if s/he has an IEP or 504 plan in regular school. Please let us know this so that we can discuss with you which details, if any, it is appropriate to share with the classroom teacher. Thanks!

Physician's Name (Child 3)

Allergies/Special Health Considerations (Child 3)

Medication authorization (Child 3)

I authorize the UVJC to administer medications that I have supplied for medical conditions noted above. I have supplied the following medications to the Director of Education, and instructions are attached to the medications supplied.

Tuition (Child 3)

Would you like to register a fourth child?

Yes
No

Fourth Child's Information

Name (Child 4)

First Last Hebrew

Date of Birth (Child 4)

Gender (Child 4)

Grade level (Child 4)

Education information (Child 4)*

Please describe your child's learning style and provide any tips you have to help the teacher succeed in working with your child. We can develop a more positive learning environment for your child when we know, in advance, if s/he has an IEP or 504 plan in regular school. Please let us know this so that we can discuss with you which details, if any, it is appropriate to share with the classroom teacher. Thanks!

Physician's Name (Child 4)

Allergies/Special Health Considerations (Child 4)

Medication authorization (Child 4)

I authorize the UVJC to administer medications that I have supplied for medical conditions noted above. I have supplied the following medications to the Director of Education, and instructions are attached to the medications supplied.

Tuition (Child 4)

Parent/Guardian 1 Information

Name*

First Last

Address*

Street Address Address Line 2 City State ZIP Code

Phone (primary)*

Phone (secondary)*

Email*

Parent/Guardian 2 Information

Name*

First Last

Address*

Street Address Address Line 2 City State ZIP Code

Phone (primary)*

Phone (secondary)*

Email*

Health insurance company*

Insurance policy number*

Insurance company contact information*

Alternative Emergency Contact (Primary)

Name*

First Last

Address*

Street Address Address Line 2 City State ZIP Code

Phone (primary)*

Phone (secondary)*

Alternative Emergency Contact (Secondary)

Name*

First Last

Address*

Street Address Address Line 2 City State ZIP Code

Phone (primary)*

Phone (secondary)*

Payment Information

You will be sent an invoice via email. Please direct any questions to Chris DePierro by email at office@uvjc.org or by phone at (603) 646-0460.

Total

$0.00