ב"ה

Jewish Teen Program

Address

Does your Teen read basic Hebrew?

YesNo
If Yes:

WellFairPoor
Does your child have any difficulties with his/her general studies? If yes, please specify:
Parent Information:
Parent 1 Name: *

First Name Last Name
Hebrew Name (if known):
Phone Number:*

Area Code Phone Number
E-mail*
Occupation:

Work Address:

Work Address:

Allergies: *
Medical Conditions, if any:*
Emergency Information:
Name:*

First Name Last Name
Relationship:
Phone Number*

Area Code Phone Number
Name:*

First Name Last Name
Relationship:
Phone Number*

Area Code Phone Number
Permissions
Permission for Emergency Medical Treatment

I authorize any adult acting on behalf of the Seacoast Chabad Hebrew School to hospitalize or secure treatment for my child/children. I further agree to pay for all charges for that care and/or treatment. It is understood that, if time and circumstances reasonably permit, The Seacoast Chabad Hebrew School will try to communicate with me prior to such treatment.
*

I agree
*

I permit my child's photos to be used by The Seacoast Chabad Hebrew School for publicity purposes.
*

I hereby give permission for my teen to attend all field trips sponsored by the The Seacoast Jewish Teen Program
Signature:*
Date:*

Month Day Year
Tuition Payment
$100 Registration Fee Per Teen (Will be charged at the submission of this form)
$800 Tuition (includes book fees & all supplies)

Early Bird Registration before May 30, 2023: Deduct $50 per child
Refer a Family: Deduct $100

No Teen will be turned away due to lack of funds.
Please choose from the following payment options for tuition:*

One time paymentMonthly payments (8 monthly payments of $100 beginning Sep 1st)I would like to request a scholarship. Please follow the link upon submission to complete the scholarship application.
Comments:
Total

$0.00

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

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Teen Information: