Torah Time Registration - ChabadofAlabama.com

Address:

Date of Birth:*

Month Day Year
Hebrew Name:
Hebrew Birthday if known:
School Currently Attending:
Grade Entering:
Parent Information:
Parent 1 Name:
Home Phone Number:

Area Code Phone Number
Work Phone Number:

Area Code Phone Number
Cell Phone Number:

Area Code Phone Number
Parent 2 Name:
Work Phone Number:

Area Code Phone Number
Cell Phone Number:

Area Code Phone Number
Emergency Contact Info:
Full Name of Emergency Contact:*

First Name Last Name
Emergency Contact Phone Number:*

Area Code Phone Number
Relationship to child:
Pediatrician Name:
Pediatrician Phone Number:

Area Code Phone Number
Allergies?
Permissions:*

Torah Time has permission to adminster first aidIf the need arises, and parents or emergency contacts cannot be reached, Torah Time has permission to have my child transported and treated at an appropriate medical facility.
Registration & Payment Information:

Torah Time tuition is $600 annually. You may pay $67 per month for 9 months or make a one time payment of $600.
Registration Options:*

I would like to pay tuition in full today: $600I would like to pay $67 per month for 9 months.
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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Student Information: