Shenzhen Hebrew School Registration Form

Child 1
Student Name *

First Name Last Name
Hebrew Name
Age *
Birth Date *

Month Day Year
Gender *

Male Female
Does you child read basic Hebrew? *

None Somewhat Well
Does your child speak/understand Hebrew? *

None Somewhat Well
Does your child have previous Jewish Education *

Yes No
If yes, please describe
Child 2
Student Name

First Name Last Name
Hebrew Name
Age
Birth Date

Month Day Year
Gender

Male Female
Does you child read basic Hebrew?

None Somewhat Well
Does your child speak/understand Hebrew?

None Somewhat Well
Does your child have previous Jewish Education

Yes No
If yes, please describe:
Parent Information
Father's Name *

First Name Last Name
Cell Phone *
Home Phone *
Office Phone *
E-mail *
Address *

Street Address

Street Address Line 2

City

Postal / Zip Code
Mother's Name *

First Name Last Name
Cell Phone *
Home Phone *
Office Phone *
E-mail *
Address *

Street Address

Street Address Line 2

City

Postal / Zip Code
Are the natural parents of the child (ren) Jewish? *

Yes No
Were there any conversions or adoptions in your family history *

Yes No
If yes, please explain:
Emergency Contact Information
Please list two contacts to be used in case of emergencies *
Emergency Contact (other than parent)
Relationship to child *
Cell Phone *
Home Phone *
Address *

Street Address

Street Address Line 2

City
Contact 2 *
Emergency Contact (other than parent)
Relationship to child *
Cell Phone *
Home Phone *
Address *

Street Address

Street Address Line 2

City
Child's physician or medical facility *
Physician's phone *
Physician's Address *

Street Address

Street Address Line 2

City
CONFIDENTIAL
As the parent(s) or legal guardian of the mentioned above students, I/we authorize any adult acting on behalf of Pudong Hebrew School to hospitalize or secure treatment for my child, I further agree to pay all charges for that care and/or treatment. It is understood that if time and circumstances reasonably permit, Pudong Hebrew School personnel will try, but are not required, to communicate with me prior to such treatment. I hereby give permission for my child to attend all field trips and outings with Pudong Hebrew School. *

Agree Do not agree
Tuition Information

The following is a tuition agreement for the Shenzhen Hebrew School. A full payment plan must be submitted to the school office before the school year begins. No child will be turned away for lack of funds.

Tuition fee:
Shenzhen Hebrew School: 480RMB/Semester (8 lessons).
Includes Registration, Supplies, Snack & Yearly Hebrew School family Shabbat dinner.

Discounts:
5% Discount for students registerd before June 2
Payments Plans *

Bill me the full payment of 480RMB/Semester (8 lessons) through credit card / bank wire
Should be Empty:

Child 1

Child 2

Parent Information

Emergency Contact Information