* = required

Children Information

    Child Name Child Date Of Birth Child School Child Entering Grade  
  Child 1*
  Child 2
  Child 3
  Child 4
 

Parent 1 Information

  Name* :
 Email* :
 
  Phones : Mobile* :
(-
Work :
(-
Home :
(-
 
 

Parent 2 Information

  Name :
Email:
 
  Phones : Mobile :
(-
Work :
(-
Home :
(-
 
 

Home Address

    Street* :
City* :
State* :
Zip* :
 

Programs & Tuition

Gedolim — Kindergarten through 1st Grade


TUITION: $800 (per child)



Tzofim L’Ktantanim — Israeli Scouts for 2nd Graders


TUITION: $800 (per child)


Billing Information

BILLING TOTALS

Tuition $ 0
Total Due $ 0
Due Today $ 0
Balance $ 0


PAYMENT PLAN: I understand that $400 will be charged to the credit card provided upon receipt of this form. I authorize 3 equal installments to be automatically charged to the credit card provided on September 1, 2014, December 1, 2014 and February 2, 2014.



 
 
 

 
 
 
 
   
 


Credit Card Information