Youth Club Registration


                        
                            Youth Club Registration
                            
                        

                        Student Information
Name*
                            
                            
                                                    
                                                    First Name
                                                
                            
                            
                                                    
                                                    Last Name
                                                
                            
                                                    
                                                    Hebrew Name
                                                
                        
Age 
Date of Birth (Month, Day, Year Format)* 
Address*    
                    
                         
                                        
                                        Street Address
                                    
                                        
                                        Address Line 2
                                    
                                    
                                    City
                                 
                                        
                                        State / Province / Region
                                      
                                    
                                    ZIP / Postal Code
                                
                                        
                                        Country
                                    
                    
                
School* 
Grade Entering* 
Gender*
			
				
				Male
			
			
				
				Female
			
Previous Jewish Education*
			
				
				Yes
			
			
				
				No
			
Please Describe
Had a psychological assessment?*
			
				
				Yes
			
			
				
				No
			
Additional Information we should know about
Medical Information
OHIP Number* 
Allergies* 
Other Medical information
Parent Information
Marital Status* 
Org. Affiliation 
Father's Name*
                            
                            
                                                    
                                                    First
                                                
                            
                            
                                                    
                                                    Last
                                                
                            
                        
Father's Work Phone*
Father's Occupation* 
Father's Cell Phone*
Father's Email*
                            
                        
Mother's Name*
                            
                            
                                                    
                                                    First
                                                
                            
                            
                                                    
                                                    Last
                                                
                            
                        
Mother's Work Phone*
Mother's Occupation* 
Mother's Cell Phone*
Mother's Email*
                            
                        
Have there been any conversions or adoptions in the family?*
			
				
				Yes
			
			
				
				No
			
Family Information
Include Your Children/s names and Birth Dates*
Emergency Contact Information
Name* 
Phone* 
Relationship* 
Tuition Information
True to our philosophy of allowing each child to a Jewish education regardless of their parent’s financial position, there is no fixed admission fee for enrollment. We do encourage all parents to make contribution of your choice to help cover the overhead expenses of the school. For more information please contact Rabbi Yisroel Fridman at 289-304-9492 
Select Program
Select The Program...*
Terms of Agreement
In the event of an emergency, Hebrew school of Performance has my permission to arrange for any necessary first-aid or care.

Hebrew school of Performance has my permission to use my child's photo in its publicity materials.
Digital Signature*