Printed fromFCIL.org

ב"ה

Programs Talmud Torah

Talmud Torah Registration

Part I: Parents’ Information
Father’s Name:*
First Name Last Name
Hebrew Name:*
Work phone:
Cell:*
E-mail*
Occupation:
Was the Father born Jewish?*

YesNo
The Father is (check one)

KohenLeviIsrael
Mother’s Name:*
First Name Last Name
Hebrew Name:
Work phone:
Cell:*
E-mail*
Was the Mother born Jewish?*

YesNo
Occupation:
Parents’ Marital Status:

MarriedDivorcedWidowed
Shul/Synagogue:*
Names and Ages of Other Children:
Are there any conversions in the family?*

YesNo
Details
Part II: Student’s Information
Full Name:*
First Name Last Name
Full Hebrew Name:*
Gender:*

MaleFemale

Address:*

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Home Phone:
School:*
Grade:
Age:*
Birth Date:*

Month Day Year
Is the child adopted?*

YesNo
Part III: Education
Does your child know the Hebrew letters?

NoneSomewhatWell
Does your child speak/understand Hebrew?

NoneSomewhatWell
Child’s Jewish education (if any):
Learning Method /Strategy your child is accustomed to:
Part IV: Behavior & Medical Information
Does your child occasionally exhibit any of the following behaviors?

BittingGrabbingHittingKickingPull HairCursing
What is the best method of handling the situation?
Other things you would like to tell us about your child?
Please list your child’s favorite activities:
Please list your child’s least favorite activities:
Explanation of Medical Concerns (if necessary):
Dietary Restrictions:
Family physician:
Phone Number
Up to date with vaccinations?

YesNo
Allergies and other known conditions: (if any)
Person to be contacted in case of an emergency (when parents cannot be reached):*
First Name Last Name
Phone Number of emergency contact:*
Relationship to child:*
I hereby consent to the administration of The Friendship Circle to take whatever medical measures they deem necessary for my child in the event of a medical emergency.*

YesNo
I permit my child’s photo to be used for publicity purposes.*

YesNo
Part V: Tuition
Tuition for 5785 (26 sessions) is $1,350.
This includes a non-refundable deposit of $150 due at registration.
Payment Options*

Full payment of $1,350Pay $150 deposit now, then $600 on September 8, 2025, and $600 on January 8, 2026.
Total

$0.00

Payment

Credit Card Paypal

Postal / Zip Code

Country

Should be Empty:

This page uses TLS encryption to keep your data secure.