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VH 2023
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New Student Registration

Select Your Track
- In-Person
CHILD INFORMATION
Name
English Hebrew
Birth Date
Time of Birth
Place of Birth
Grade Entering (Sept 2023):
What school does your child attend?
Does any of your children hold a Public School IEP?
- Yes
- No
Child's Name
Details & Accomadations:
Any considerations, such as learning disorder or difficulty, the school should be aware of? (Confidential):
Does your child read basic Hebrew?
- None
- Somewhat
- Well
Is the natural mother of the child Jewish?
- Yes
- No
Were there any conversions or adoptions in your family? (mother, grandmother etc)
- Yes
- No
Please describe
Please note: All conversions must be made through a registered Beth Din that is certified by the Chief Rabbinate of Israel. We do not Bar or Bat Mitzvah anyone whose mother is not Jewish by Israel’s Chief Rabbinate Halachic standards.
PARENT INFORMATION
Check yes if all Parental information is included on membership forms or past Village Hebrew Registration Forms (Note: If any changes then what was previously submitted – please complete this form)
- Yes
- No
Father's Name
First Last
Father's Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Home Phone Number
Mobile Phone Number
Email
Work Phone Number
Mother's Name
First Last
Mother's Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Mobile Phone Number
Home Phone Number
Email
Work Phone Number
EMERGENCY INFORMATION
Please list two contacts to be used in case of emergencies (other than your home and business numbers).
Emergency Contact #1:
Relationship
Home Phone:
Work Phone
Mobile Phone
Emergency Contact #2:
Relationship
Home Phone:
Work Phone
Mobile Phone
Doctor
Doctor's Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Doctor's Phone Number
Health Insurance
Group #
ID #
Allergies or other Medical Condition (confidential):
As the parent(s) or legal guardian of
Name
First Last
I/we authorize any adult acting on behalf of Village Hebrew to hospitalize or secure treatment for my child, I further agree to pay all charges for that care and/or treatment. It is understood that if time and circumstances reasonably permit, Village Hebrew personnel will try, but are not required, to communicate with me prior to such treatment. I hereby give permission for my child to participate in all school activities, join in class and school trips on and beyond school properties and allow my child to be photographed while participating in Village Hebrew activities.
Digital signature of parent/legal guardian
Date
I was referred to Village Hebrew by
I would love to volunteer and take a position as a Class Mom, Birthday packages or Individual HS Event committee. (Not all require volunteering on Village Hebrew slotted days and times)
- Yes
- No
Digital Signature
I/We understand that the Parent Social & Curriculum Night, Family Shabbat Dinner and the End of the Year Celebration are Mandatory events. Dates will be provided with our Village Hebrew calendar at the start of the year.
The best compliment is a referral. Please suggest a family that would appreciate an invite to our future programs:
Name
First Last
Phone
Email
The primary objective of my child’s Hebrew School experience is to
TUITION AGREEMENT
The following document is a tuition agreement with Village Hebrew. The agreement explains the tuition fees, payment plans and refund policies. Please read it through carefully and sign it on the line below. You will receive an acceptance letter including all schedule and class information upon receipt of the signed tuition agreement along with full payment. The tuition for Village Hebrew is as follows: Tuition fee per child for the year: $1,200 Registration & Book fee per child: $100 Security fee: $200 per child
POLICIES
- PLAN A: You may pay the entire amount in full with a check, cash or credit card enclosed with your registration forms.
- PLAN B: you may split total payment equally into two payments. First installment is due prior to the first day of Hebrew School with your registration forms. The second installment must be submitted as a post dated check or credit card (December 1, 2023) with the return of this form.
You may choose from the following payment methods:
If you require an alternate payment plan, please contact Village Hebrew Rabbi: Rabbi Cohen 631-585-0521
A student that is becoming a Bar/Bat mitzvah in the current Village Hebrew year of 2023/2024 must be paid in FULL prior to the start of Hebrew School. (PLAN A ONLY).
There are no refunds or credits for days missed due to illness, holidays or family vacations.
I will be paying the deposit of $100 and the yearly tuition by
- Credit Card (3% SURCHARGE WILL BE PROCESSED AT TIME OF CC PAYMENT)
- Cash or Check
Card Number
Card Holder's Name
Expiration Date
Security Code

Tel: 631.585.0521 • villagehebrew@gmail.com • https://www.facebook.com/myvillagehebrew/

Village Hebrew

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Our Program
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VH 2023
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Contact