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(702) 901-8383 ext 4
[email protected]
8551 Vegas Drive, Las Vegas, NV
Tuesdays and Thursdays 04:00PM to 07:00PM
Registration Form
Registration Form
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*
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How many students are you registering?
*
1 Student
2 Students
3 Students
4 Students
Student Profile 1
First Name
*
Last Name
*
Hebrew First Name
*
Hebrew Last Name
*
Date of Birth
*
MM slash DD slash YYYY
School Attending
*
Grade Entering
*
Please Select
Kindergarten
First
Second
Third
Fourth
Fifth
Sixth
Seventh
Hebrew Reading Proficiency
*
Please Select
None
Somewhat
Well
Previous Jewish Education
*
Please Select
Yes
No
Have there been any conversions or adoptions in the family?
*
Please Select
Yes
No
Student Profile 2
First Name
*
Last Name
*
Hebrew First Name
*
Hebrew Last Name
*
Date of Birth
*
MM slash DD slash YYYY
School Attending
*
Grade Entering
*
Please Select
Kindergarten
First
Second
Third
Fourth
Fifth
Sixth
Seventh
Hebrew Reading Proficiency
*
Please Select
None
Somewhat
Well
Previous Jewish Education
*
Please Select
Yes
No
Have there been any conversions or adoptions in the family?
*
Please Select
Yes
No
Student Profile 3
First Name
*
Last Name
*
Hebrew First Name
*
Hebrew Last Name
*
Date of Birth
*
MM slash DD slash YYYY
School Attending
*
Grade Entering
*
Please Select
Kindergarten
First
Second
Third
Fourth
Fifth
Sixth
Seventh
Hebrew Reading Proficiency
*
Please Select
None
Somewhat
Well
Previous Jewish Education
*
Please Select
Yes
No
Have there been any conversions or adoptions in the family?
*
Please Select
Yes
No
Student Profile 4
First Name
*
Last Name
*
Hebrew First Name
*
Hebrew Last Name
*
Date of Birth
*
MM slash DD slash YYYY
School Attending
*
Grade Entering
*
Please Select
Kindergarten
First
Second
Third
Fourth
Fifth
Sixth
Seventh
Hebrew Reading Proficiency
*
Please Select
None
Somewhat
Well
Previous Jewish Education
*
Please Select
Yes
No
Have there been any conversions or adoptions in the family?
*
Please Select
Yes
No
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Please select if each of the following family members are Jewish
Father
*
Please Select
Yes
No
Mother
*
Please Select
Yes
No
Paternal Grandfather
*
Please Select
Yes
No
Paternal Grandmother
*
Please Select
Yes
No
Maternal Grandfather
*
Please Select
Yes
No
Maternal Grandmother
*
Please Select
Yes
No
Parent Information
Father's First Name
*
Father's Last Name
*
Phone
*
Email
*
Mother's First Name
*
Mother's Last Name
*
Phone
*
Email
*
Address
*
Street Address
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Emergency Contact
Emergency Contact 1
*
Phone
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Emergency Contact 1
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Phone
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CONFIDENTIAL: Does your child have any allergies or other medical condition we should be aware of? If yes, please describe them and indicate special precautions or care needed.
Payment Period
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Yearly ($850)
Monthly ($85)
Total Payable
Price:
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