2023-24 HEBREW PROGRAMS REGISTRATION FORM

Please complete the form below. Required fields marked with an asterisk *

2023-24 HEBREW PROGRAMS REGISTRATION FORM

STUDENT INFORMATION

First Name*

Answer required for "First Name"

Last Name*

Answer required for "Last Name"

Date of Birth*

Answer required for "Date of Birth"

Grade as of September 2023*

Answer required for "Grade as of September 2023"

Student Phone*

Number Required

Student Email*

Answer required for "Student Email"

Student School*

Answer required for "Student School"

Synagogue *

Answer required for "Synagogue "

PARENTS INFORMATION

Parent 1 First Name*

Answer required for "Parent 1 First Name"

Parent 1 Last Name*

Answer required for "Parent 1 Last Name"

Parent 2 First Name*

Answer required for "Parent 2 First Name"

Parent 2 Last Name*

Answer required for "Parent 2 Last Name"

Parent 1 Phone*

Number Required

Parents 2 Phone*

Number Required

Parent 1 Email*

Answer required for "Parent 1 Email"

Parents 2 Email*

Answer required for "Parents 2 Email"

Address*

Answer required for "Address"

City*

Answer required for "City"

State*

Answer required for "State"

Zip Code*

Answer required for "Zip Code"

In Case of Emergency, Person to Contact (If Not Parents)*

Answer required for "In Case of Emergency, Person to Contact (If Not Parents)"

HEBERW PROGRAM TO CHOOSE

I Request Hebrew Credit (only available for below options 1, 2, and 3) *

Answer required for "I Request Hebrew Credit (only available for below options 1, 2, and 3) "

Yes

I am registering for:*

Answer required for "I am registering for:"

Day/s of Learning*

Answer required for "Day/s of Learning"

Tuesday and Thursday (preferable)

Monday and Wednesday

Monday (a Second day with a Shin Shin will be assigned later)

Tuesday (a Second day with a Shin Shin will be assigned later)

Wednesday (a Second day with a Shin Shin will be assigned later)

Thursday (a Second day with a Shin Shin will be assigned later)

Other:

If "Other" Was Chosen Above, Please Explain

Answer required for "If \"Other\" Was Chosen Above, Please Explain"

Describe Any Special Learning Concerns or Considerations Which @akiva Faculty Should Be Made Aware

Answer required for "Describe Any Special Learning Concerns or Considerations Which @akiva Faculty Should Be Made Aware "

PARENT OR GUARDIAN SIGNATURE

Parent or Guardian, Print Your Name and Date*

Answer required for "Parent or Guardian, Print Your Name and Date"

Please fix the highlighted areas below before submitting.

2023-24 HEBREW PROGRAMS REGISTRATION FORM