Lake Success Jewish Center Hebrew School
354 Lakeville Road – Great Neck, New York 11020
Phone – 516-466-0569 Fax – 516-466-7038
www.lakesuccessjc.org
REGISTRATION FORM 2019-2020
Please complete one form for each child you enroll.
Child’s Name ______________________________ Hebrew Name ________________________
Birth Date ________________________________ Age _________________________________
Public School ______________________________ Grade in September ___________________
Address _______________________________________________________________________
______________________________________________________________________________
Parent #1: Name _______________________________ E-mail _________________________
Home Phone ________________ Work Phone ________________ Cell __________________
Parent #2: Name _______________________________ E-mail _________________________
Home Phone ________________ Work Phone ________________ Cell __________________
THIS SECTION MUST BE COMPLETED
IN CASE OF EMERGENCY NOTIFY _______________________ PHONE _________________
PHYSICIAN’S NAME __________________________________ PHONE _________________
Emergency Medical Consent:
I ______________________________, the undersigned, the parent or legal guardian of the child named on this registration form, do hereby give authorization for professional medical personnel to provide emergency medical treatment in the event that neither parent (guardian) can be contacted for such permission.
Signature _____________________________________________ Date _____________________
FEE SCHEDULE FOR 2019-2020
► Mechina (ages 6-7) $125
Wednesdays @ 4:30-6:00 PM
► Aleph (ages 8-9) $300
Thursdays @ 4:30-6:00 PM
► All Other Students (ages 9-13) $300
Wednesdays @ 4:15-6:15 PM
Hebrew School Fees are due prior to the start of classes.
No student will be permitted to attend class unless all fees are paid.
Pay via check made out to Lake Success Jewish Center
or via credit card at www.lakesuccessjc.org/donate
I, ___________________________________, agree to pay all required fees and charges prior to the start of Hebrew School classes for the 2019-2020 school year. I understand that failure to pay all financial obligations may jeopardize my student’s participation in class.
Signature _______________________________________