Cheder Form 2023-2024

Family Name:*
Cell Number*

Area Code Phone Number
E-mail*

Family Address*

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Emergency Contact:*
Mothers Hebrew Name:*
Child Information

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Child #1 Hebrew Name*
Child #1 Age* ex: 7
Child #1 Birth Date*

Month Day Year
Child #1 Hebrew Birthday* Ex: 1 Tishrei 5782
Add Another Child
Child #2 Hebrew Name*
Child #2 Age* Ex: 10
Child #2 Birth Date*

Month Day Year
Child #2 Hebrew Birthday* Ex: 1 Tishrei 5782
Add Another Child
Child #3 Hebrew Name*
Child #3 Age* ex: 9
Child #3 Birth Date*

Month Day Year
Child #3 Hebrew Birthday* Ex: 1 Tishrei 5782
Add Another Child
Child #4 Hebrew Name*
Child #4 Age* ex: 11
Child #4 Birth Date*

Month Day Year
Child #4 Hebrew Birthday* Ex: 1 Tishrei 5782
Add Another Child
Child #5 Hebrew Name*
Child #5 Age* ex: 5
Child #5 Birth Date*

Month Day Year
Child #5 Hebrew Birthday* Ex: 1 Tishrei 5782
Add Another Child
Child #6 Hebrew Name*
Child #6 Age*
Child #6 Birth Date*

Month Day Year
Child #6 Hebrew Birthday* Ex: 1 Tishrei 5782
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Dear Teachers,

As we are forever indebted and grateful for all your hard work, your children come to Cheder for half price.

When regestering your child(ren) please check off the $180 option.

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K5 - 8th Boys and Girls:

$360 per child.

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For those who are splitting the payments in half:

The second payment of $180 (per child) will be charged on January 15th 2024.

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For those who are splitting the payments into thirds:

The second payment of $120 (per child) will be charged on January 15th 2024.

The third payment $120 (per child) will be charged on March 19th 2024.
Cost Child #1*

$120$180$360
Cost Child #2*

$120$180$360
Cost Child #3*

$120$180$360
Cost Child #4*

$120$180$360
Cost Child #5*

$120$180$360
Cost Child #6*

$120$180$360
Total

$0.00

Yes, I'd like to donate the cost of processing this transaction by adding 2.5%
I would like to deduct my child(rens) tuition from my paycheck?*

YesNo

Payment*

Credit Card

We accept Visa, MasterCard, American Express, Discover
Credit Card Number	Security Code
Name on Card
Expiration Month	Expiration Year

Billing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Should be Empty:

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