Cheder Form 2021 - Bader Hillel Academy

Family Name:*

Cell Number*

Area CodePhone Number

E-mail*

Family Address*

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

Emergency Contact:*

Mothers Hebrew Name:*

Child Information

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Child #1 Hebrew Name*

Child #1 Age*ex: 7

Child #1 Birth Date*

MonthDayYear

Child #1 Hebrew Birthday*Ex: 1 Tishrei 5782

Add Another Child

Child #2 Hebrew Name*

Child #2 Age*Ex: 10

Child #2 Birth Date*

MonthDayYear

Child #2 Hebrew Birthday*Ex: 1 Tishrei 5782

Add Another Child

Child #3 Hebrew Name*

Child #3 Age*ex: 9

Child #3 Birth Date*

MonthDayYear

Child #3 Hebrew Birthday*Ex: 1 Tishrei 5782

Add Another Child

Child #4 Hebrew Name*

Child #4 Age*ex: 11

Child #4 Birth Date*

MonthDayYear

Child #4 Hebrew Birthday*Ex: 1 Tishrei 5782

Add Another Child

Child #5 Hebrew Name*

Child #5 Age*ex: 5

Child #5 Birth Date*

MonthDayYear

Child #5 Hebrew Birthday*Ex: 1 Tishrei 5782

K5 - 8th Boys and Girls:

$360 per child.

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For those who are splitting the payments in half:

The second payment of $180 (per child) will be charged on January 10th 2022.

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For those who are splitting the payments into thirds :

The second payment of $120 (per child) will be charged on January 10th 2022.

The third payment $120 (per child) will be charged on March 25th 2022 .

Cost Child #1*

$120$180$360

Cost Child #2*

$120$180$360

Cost Child #3*

$120$180$360

Cost Child #4*

$120$180$360

Cost Child #5*

$120$180$360

Total

$0.00

Yes, I'd like to donate the cost of processing this transaction by adding 2.5%

I would like to deduct my child(rens) tuition from my paycheck?*

YesNo

Payment*

Credit Card

Credit Card Type
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