Student InformationName* First Name Last Name Hebrew Name Date of BirthGrade EnteringPlease check all applicable* Medical information is same as last year Home address and phone / cell number are same Parental status and information are same Parental employment and contact info is same Emergency contacts and info is same I agree to the same disclaimer I signed last year for JYN Hebrew School If any of the above is changed please specify belowTuition Fees$725.00 Tuition • Charitable tax receipts will be issued for the full amount of all tuition fees paid. $75.00 Deposit • This is non-refundable and must be paid by credit card at the time of registration.Payment InformationSave $50.00 - Early bird registration until May 15.Please Choose Payment PlanPay In FullThree PaymentsPlease Choose Payment MethodCashChequeCredit Card (Due to credit card company fees, Visa & MC will be processed with an additional 3% surcharge)Card NumberName on CardExpiration Date (mm/yy)Security CodeBilling Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Promo Discount CodeDisclaimerAs the parent(s) or legal guardian of the above child, I/we authorize any adult acting on behalf of JYN Hebrew School to hospitalize or secure treatment for my/our child, I/we further agree to pay all charges for that care and/or treatment. It is understood that if time and circumstances reasonably permit, JYN Hebrew School personnel will try, but are not required, to communicate with me/us prior to such treatment. I/we hereby give permission for my/our child to participate in all school activities, join in class and school trips on and beyond school properties and allow my/our child to be photographed while participating in Hebrew School activities. I/we also understand that all liability and costs resulting from damage to property and/or personal injury caused or attributable to my/our child/children will be my/our responsibility and I/we agree to fully indemnify and save JYN Hebrew School and it’s associates, teachers and agents harmless therefrom. I/we consent to JYN Hebrew School’s use of our personal information and of our child/children at its discretion in pursuit of school activities. Refund Policy: Before November 15 - 50% of tuition fees refund. Before December 15 - 25% of tuition fees refund. After December 15– No refund. There is no refund for daily/weekly absences. Please note that all cancellations must be made via email. ParentsMom* First Name Last Name Mom's Email* Mom's Cell*Dad* First Name Last Name Dad's Email* Dad's Cell*Digital Signature