School-Enrollment-Form

K’hilat Ha’ Aloneem

School Enrollment Application - Fall 2009

Registration is due by September 5, 2009

Child’s Name: ____________________________

Birthdate: ______________

Sex: M F Grade: ________

Child’s Name: ____________________________

Birthdate: ______________

Sex: M F Grade: ________

Child’s Name: ____________________________

Birthdate: ______________

Sex: M F Grade: ________

Name of Parent/Guardian #1:

____________________________________________________________

Parent/Guardian #1: Phone: __________________Cell:___________________

Work: _________________

Address:

______________________________________________________________________________

City: __________________________________

State:__________________

Zip:____________________

Email Address: ___________________________________________________________________________

Name of Parent/Guardian #2:

____________________________________________________________

Parent/Guardian #2: Phone: __________________Cell:___________________

Work: __________________

Address:

______________________________________________________________________________

City: __________________________________

State:__________________

Zip:____________________

Email Address:

__________________________________________________________________________

I permit my child to attend religious school conducted by K’hilat Ha’Aloneem and release all its officers, directors, employees independent contractors, advisors, and agents from any and all liability that may arise out of my child’s participation in such activity or events related to the school. These events may include athletic activities and off-site walks. The school sessions and expectations are more fully described on accompanying promotional information. I hereby authorize K’hilat Ha’Aloneem or any authorized chaperone to call a physician for necessary care for my child in case of emergency and agree to pay all expenses incurred.

No child may be released to a person other than those signing below or with written permission from those signing below. Fees are not refunded for missed sessions.

The undersigned agrees to pay all school fees as stated below and to participate consistent with the documents provided by the school.

Signature:

__________________________________________

Print Name:

__________________________________________

Fees:

_____First student in family…........$220

_____Second student in family…...$165

_____Third, etc. student in family…$110

Total Amount Due:

Circle one:

1 child ($220)

2 children ($385)

3 children ($495)

Payment may be made by one of the following 3 options:

Pay in full by check

Pay in full by credit card

Pay in 2 equal installments with your credit card. Automatic debiting will be done in 2 consecutive months after receipt of credit card information. (See separate form for credit card payment)

Supplemental Information:

Please let us know if your child has any special learning needs or challenges: __________________________

________________________________________________________________________________________

Please let us know if your child has any behavioral needs or challenges:

_____________________________

________________________________________________________________________________________

Describe any medications your child is takes regularly: ____________________________________________

Please let us know of any allergies your child has: ________________________________________________

Please let us know of any serious medical conditions your child has: _________________________________

________________________________________________________________________________________

EMERGENCY CONTACT (if parent(s)/guardian(s) are unavailable):

Name: _________________________________

(Please Print)

Phone: Cell: _____________________________

Work:__________________________________

Mail completed applications to:

K’hilat Ha’Aloneem

Attention: Sunday School

530 West El Roblar

Meiners Oaks, California

Credit Card Information:

For Payment of K’hilat Ha’Aloneem Religious School Fees

Name on card: _____________________________________

(Please Print)

Billing Address:

Street/Box: _______________________________________

City: _____________________ State: ____ Zip: ________

I agree to pay the amount of $ _________ billed to my credit card listed below.

Please provide the following information:

Type of Card: _______________________

Card Number: ______________________________

(MasterCard/Visa/American Express/Discovery)

Expiration Date: _______ /________ Verification Code: (from back of card): __________

Month Year

(3 or 4 digits)

Signature: __________________________

Pay in full by credit card.

Pay in 2 equal installments with your credit card.

(Automatic debiting will be done in 2 consecutive months after receipt of credit card information.)

Circle Option Choice: Option 1 Option 2