PAYQUIQ ONLINE :: The Faster Smarter Way to Pay

Religious school is open to synagogue members and on a trial basis.

I am a member of the synagogue.
I am NOT currently affiliated. I would like to be contacted about membership.

Student 1

* First Name

* Last Name

Hebrew Name (if known)

Date of Birth

School in Fall

Student Phone

Student Email

Is your child new to United Hebrew Schools?

Religious school grade entering Fall 2021

Individual Hebrew Group

Yes

$400.00

Small group Hebrew is included in tuition. If you choose to have individual Hebrew learning, please choose this option.

Medical and Specific Needs

Food Allergies

Other considerations

Does the student have medical conditions, dietary restrictions special needs, or anything else we should be made aware to help ensure a successful year?

Would you like to discuss any physical, learning or family arrangement that may affect the student's performance or adjustment in school?

	Yes
	No

Doctor Name

Doctor Phone Number

Student 2

First Name

Last Name

Date of Birth

Hebrew Name (if known)

School

Student Phone

Student Email

Is your child new to United Hebrew Schools?

Religious school grade entering Fall 2021

Individual Hebrew Group

Yes

$400.00

Small group Hebrew is included in tuition. If you choose to have individual Hebrew learning, please choose this option.

Medical and Specific Needs

Food Allergies

Other considerations

Does the student have medical conditions, dietary restrictions special needs, or anything else we should be made aware to help ensure a successful year?

Would you like to discuss any physical, learning or family arrangement that may affect the student's performance or adjustment in school?

	Yes
	No

Doctor Name

If different from Student 1

Doctor Phone Number

If different from student 1

Student 3

First Name

Last Name

Hebrew Name (if known)

Date of Birth

School

Student Phone

Student Email

Is your child new to United Hebrew Schools?

Religious school grade entering Fall 2021

Individual Hebrew Group

Yes

$400.00

Small group Hebrew is included in tuition. If you choose to have individual Hebrew learning, please choose this option.

Medical and Specific Needs

Food Allergies

Other considerations

Does the student have medical conditions, dietary restrictions special needs, or anything else we should be made aware to help ensure a successful year?

Would you like to discuss any physical, learning or family arrangement that may affect the student's performance or adjustment in school?

	Yes
	No

Doctor Name

If different from Student 1

Doctor Phone Number

If different from Student 1

Student 4

First Name

Last Name

Hebrew Name (if known)

Date of Birth

School

Student Phone

Student Email

Is your child new to United Hebrew Schools?

Religious school grade entering Fall 2021

Individual Hebrew Group

Yes

$400.00

Small group Hebrew is included in tuition. If you choose to have individual Hebrew learning, please choose this option.

Medical and Specific Needs

Food Allergies

Other considerations

Does the student have medical conditions, dietary restrictions special needs, or anything else we should be made aware to help ensure a successful year?

Would you like to discuss any physical, learning or family arrangement that may affect the student's performance or adjustment in school?

	Yes
	No

Doctor Name

If different from Student 1

Doctor Phone Number

If different from Student 1

Parent/Guardian Information

Parent/Guardian 1 Contact Information

* Parent / Guardian 1 Name

Street Address

City

State

Zip

* Preferred Contact #

Alternate Phone #

* Email

Parent/Guardian 2 Contact Information

Parent / Guardian 2 Name

Address (if different from above)

Preferred Contact #

Alternate Phone #

Please provide one EMERGENCY CONTACT to be notified if both parents are unreachable.

* Name & Relationship

* Phone

Policy and Release Agreement

Please verify below that you and your student(s) have reviewed the information provided in our Policies and Procedures handbook. The handbook has been sent in an email. Please contact the school office to request a copy.

The Policies of United Hebrew Congregation Schools should be read yearly and understood by both the parents / guardians and students.

* I agree to all of the policies stated in the 2021-2022 Parent Handbook

	I agree
	I do not agree

Emergency Release

If in the judgement of the UH authorities, emergency treatment is required, I authorize my child to be transported by ambulance to a hospital for treatment. I also understand that the local ambulance service does reserve the right to convey the patient to the nearest definitive care hospital of their choice, should they deem it necessary. I hereby authorize the physician(s) at the hospital to give emergency treatment to my child.

	I agree to the statements above regarding emergency care of my child
	I do not authorize the emergency care of my child as stated above. I agree to provide United Hebrew Schools with specific instructions regarding the emergency care of my child.

* Parent 1 Signature

* Student 1 Signature

Student 2 Signature

Student 3 Signature

Student 4 Signature

Tuition and Donations

There is one price for school at United Hebrew. This cost includes religious school, Hebrew education, retreats, b'nai mitzvah fee, technology fee, security fee and teacher appreciation. A late fee of $50 per family will be applied starting August 1, 2021.

Teacher Appreciation Donation $

If you would like to add an additional amount for Teacher Appreciation to be gifted at the end of the school year, please do so here. The names of all contributing families will be listed in a card to be given to the teachers.

Scholarship Donation $

Assists congregational families in need with Religious School tuition and fees

I would like to pay my tuition in installments with the first transaction processed today.

Account Details

Enter your name and e-mail address for your confirmation:

*E-mail

*First Name

*Last Name

Payment Information

Account

Online Fee:

Credit Card

Name on Card

Card Type

Card Number

Expiration Date

Card Verification Number

Address Line 1

City

State/Province

Zip

Comments

2021-2022 (5782) Religious School Registration