Online Enrollment Form

CONDITIONS OF ENROLLMENT:

General:

By parents enrolling their child(ren) in Esformes Hebrew Academy (EHA), students and parents agree to abide by all of the Conditions of Enrollment and standards of conduct as set forth by EHA as well as the rules and regulations established by EHA for the health, safety, and welfare of the students. Your child will not be accepted, verbally or in writing, unless all forms and full payment have been sent to the office.

Tuition and Installments:

Your first installment and fees are non-refundable unless you were not accepted or if you meet our refund policy. (See Below)

Registration fees are $350 per child. Full tuition installment payments will begin in June 1st, 2020 ending in FULL on March 1, 2021. I agree that in accordance to the monthly installments full tuition will be paid in full by March 1, 2021. I authorize EHA to charge the payment method in my account for the monthly installments. I agree and understand that if my first installment payment is not made according to the agreement my child(ren)’s spot could be released.

Financial Fees:

All credit cards are subject to a 3% convenience fee. All returned checks are subject to a $35 returned item fee.

Father's Name*

First Name Last Name

Mother's Name*

First Name Last Name

Home Phone Number*

Area Code Phone Number

Father's Cell Number*

Area Code Phone Number

Father's E-mail*

Mother's Cell Number*

Area Code Phone Number

Mother's Email*

Address*

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

Marital Status*

Have there been any adoptions or conversions in the family*

Yes No

Child 1 Name*

First Name Last Name

Child 1 Gender*

Male Female

Child 1 Hebrew Name*

Child 1 Hebrew Birth Date*

If you do not know your child's Hebrew date of birth, please click here .

Child 1 English Birth Date*

Month Day Year

Child 1 Incoming Preschool Level* Please select Grade Level AND Full or Part Time

Torah Tots/Pre-K2 Pre-K (3yr olds & 4yr olds) Part-Time Full-Time No Preschooler

Child 1 Incoming Grade Level*

Child 1 Type of Allergy*

What level is his/her reaction?*

Mild-coughing/tummy ache Moderate-vomiting, etc Severe-administer Epipen N/A

What happens if a reaction occurs (symptoms, Epi-pen, vomiting, etc.)* Type N/A if no allergies

If your child has a therapist, please provide the name and contact phone number

Does your child have an IEP or psychological testing?* If you answer "yes", please provide a copy to the school office

Yes No

Other Medical Information:* Type N/A if no other medical information

Child 2 Name

First Name Last Name

Child 2 Gender

Male Female

Child 2 Hebrew Name

Child 2 Hebrew Birth Date

If you do not know your child's Hebrew date of birth, please click here .

Child 2 English Birth Date

Month Day Year

Child 2 Incoming Preschool Level Please select Grade Level AND Full or Part Time

Torah Tots/Pre-K2 Pre-K (3yr olds & 4yr olds) Part-Time Full-time

Child 2 Incoming Grade Level

Kindergarten 1st Grade 2nd Grade 3rd Grade 4th Grade 5th Grade 6th Grade 7th Grade 8th Grade

Child 2 Type of Allergy

What level is his/her reaction? Type N/A if no allergies

Mild-coughing/tummy ache, etc. Moderate-vomiting,etc Severe-administer Epipen N/A

What happens if a reaction occurs (symptoms, Epi-pen, vomiting, etc.) Type N/A if no allergies

If your child has a therapist, please provide the name and contact phone number

Does your child have an IEP or psychological testing?* If you answer "yes", please provide a copy to the school office

Yes No

Other Medical Information Type N/A if no other medical information

Child 3 Name

First Name Last Name

Child 3 Hebrew Name

Child 3 Gender

Male Female

Child 3 Hebrew Birth Date

If you do not know your child's Hebrew date of birth, please click here.

Child 3 English Birth Date

Month Day Year

Child 3 Incoming Preschool Level Please select Grade Level AND Full or Part Time

Torah Tots/Pre-K2 Pre-K (3yr olds & 4yr olds) Part-Time Full-Time

Child 3 Incoming Grade Level

Kindergarten 1st Grade 2nd Grade 3rd Grade 4th Grade 5th Grade 6th Grade 7th Grade 8th Grade

Child 3 Type of Allergy

What level is his/her reaction? Type N/A if no allergies

Mild-coughing/tummy ache Moderate-vomiting, etc Severe-administer Epipen N/A

What happens if a reaction occurs (symptoms, Epi-pen, vomiting, etc.) Type N/A if no allergies

If your child has a therapist, please provide the name and contact phone number

Does your child have an IEP or psychological testing?* If you answer "yes", please provide a copy to the school office

Yes No

Other Medical Information Type N/A if no other medical information

Child 4 Name

First Name Last Name

Child 4 Hebrew Name

Child 4 Gender

Male Female

Child 4 Hebrew Birth Date

If you do not know your child's Hebrew date of birth, please click here.

Child 4 English Birth Date

Month Day Year

Child 4 Incoming Preschool Level Please select Grade Level AND Full or Part Time

Torah Tots/Pre-K2 Pre-K (3yr olds & 4yr olds) Part-Time Full-Time

Child 4 Incoming Grade Level

Kindergarten 1st Grade 2nd Grade 3rd Grade 4th Grade 5th Grade 6th Grade 7th Grade 8th Grade

Child 4 Type of Allergy

What level is his/her reaction? Type N/A if no allergies

Mild-coughing/tummy ache Moderate-vomiting, etc Severe-administering Epipen N/A

What happens if a reaction occurs (symptoms, Epi-pen, vomiting, etc.) Type N/A if no allergies

If your child has a therapist, please provide the name and contact phone number

Does your child have an IEP or psychological testing?* If you answer "yes", please provide a copy to the school office

Yes No

Other Medical Information Type N/A if no other medical information

Child 5 Name

First Name Last Name

Child 5 Hebrew Name

Child 5 Gender

Male Female

Child 5 Hebrew Birth Date

If you do not know your child's Hebrew date of birth, please click here.

Child 5 English Birth Date

Month Day Year

Child 5 Incoming Preschool Level Please select Grade Level AND Full or Part Time

Torah Tots/Pre-K2 Pre-K (3yr olds & 4yr olds) Part-Time Full Time

Child 5 Incoming Grade Level

Kindergarten 1st Grade 2nd Grade 3rd Grade 4th Grade 5th Grade 6th Grade 7th Grade 8th Grade

Child 5 Type of Allergy

What level is his/her reaction? Type N/A if no allergies

Mild-coughing/tummy ache Moderate-vomiting, etc Severe-administer Epipen N/A

What happens if a reaction occurs (symptoms, Epi-pen, vomiting, etc.) Type N/A if no allergies

If your child has a therapist, please provide the name and contact phone number

Does your child have an IEP or psychological testing?* If you answer "yes", please provide a copy to the school office

Yes No

Other Medical Information Type N/A if no other medical information

Child 6 Name

First Name Last Name

Child 6 Hebrew Name

Child 6 Gender

Male Female

Child 6 Hebrew Birth Date

If you do not know your child's Hebrew date of birth, please click here.

Child 6 English Birth Date

Month Day Year

Child 6 Incoming Preschool Level Please select Grade Level AND Full or Part Time

Torah Tots/Pre-K2 Pre-K (3yr olds & 4yr olds) Part-Time Full time

Child 6 Incoming Grade Level

Kindergarten 1st Grade 2nd Grade 3rd Grade 4th Grade 5th Grade 6th Grade 7th Grade 8th Grade

Child 6 Type of Allergy

What level is his/her reaction? Type N/A if no allergies

Mild-coughing/tummy ache Moderate-vomiting, etc Severe-administer Epipen N/A

If your child has a therapist, please provide the name and contact phone number

Does your child have an IEP or psychological testing?* If you answer "yes", please provide a copy to the school office

Yes No

Other Medical Information Type N/A if no other medical information

Physician's Name*

Physician's Phone Number*

Area Code Phone Number

Insurance Name*

Insurance ID Number*

Emergency Contact #1 Name* Non-Parent Only

Emergency Contact #1 Number*

Emergency Contact #2 Name* Non-Parent Only

Emergency Contact #2 Number*

Emergency Contact #3 Name* Non-Parent Only

Emergency Contact #3 Number*

Release and Waiver:

Images:

I grant EHA permission to use my child(ren)’s name, image, likeness, or recording in connection with any promotional materials including, but not limited to, brochures, media of any kind, video, websites, advertising, and broadcasts.

Photo Release Policy*

Agree Disagree

Waiver and Release:

By submitting this form, I understand that participation in EHA activities involves a certain degree of risk and can be physically, mentally, and emotionally demanding. I have carefully considered the risk involved and agree to allow my child(ren) to participate in these activities. I also understand that participation in these activities is entirely voluntary and requires participants to abide by applicable rules and standards of conduct as set forth by EHA. I understand that EHA is independently owned, and operated.. I understand that EHA is independently owned, operated and controlled.

IN CONSIDERATION OF THE OPPORTUNITY TO SEND MY CHILD TO EHA, AND BY REGISTERING AND SENDING MY CHILD TO SCHOOL, I, MYSELF AND ON BEHALF OF MY CHILD, HEREBY AGREE TO RELEASE AND HOLD HARMLESS EHA AND ITS EMPLOYEES, DIRECTORS, OFFICERS, AND VOLUNTEERS AS WELL AS ITS AFFILIATES AND ALL OTHER ORGANIZATIONS ASSOCIATED WITH EHA FROM ANY AND ALL CLAIMS OR LIABILITY ARISING OUT OF THIS PARTICIPATION.

The World Health Organization declared the novel coronavirus, COVID-19, a pandemic. COVID-19 is highly contagious and is believed to spread mainly from person-to-person contact. As a result, federal, state, and local governments and federal and state health agencies recommend social distancing and have, in many locations, prohibited the congregation of groups of people over the past several weeks. Chabad Lubavitch of Greater Daytona (the "Chabad") has put precautions in place to reduce the spread of COVID-19; however, the Chabad cannot guarantee that you or your family, including your child(ren), will not become exposed to or infected with COVID-19. Further, because of the number of individuals involved in Camp Gan Israel and the fact that many infected individuals appear to be asymptomatic, attending this activity could increase your and your child(ren)’s risk of contracting COVID-19.

By submitting this form, I acknowledge the contagious nature of COVID-19 and voluntarily assume the risk that my child(ren) and I may be exposed to or infected by COVID19. I also acknowledge that by attending Chabad Esformes Hebrew Academy, such exposure or infection may result in personal injury, illness, disability, and/or death. I understand that the risk of becoming exposed to or infected by COVID-19 at Chabad Esformes Hebrew Academy may result from the actions, omissions, or negligence of myself and others, including, but not limited to, Chabad employees, contractors, volunteers, members, and participants and their families.

I voluntarily agree to assume all of the foregoing risks and accept sole responsibility for any injury to my child(ren) or myself (including, but not limited to, personal injury, disability, and death), illness, damage, loss, claim, liability, or expense of any kind that I or my child(ren) may experience or incur in connection with my child(ren)’s attendance at the Chabad or participation in Camp Gan Israel ("Claims").

On my behalf, and on behalf of my children, I hereby release, covenant not to sue, discharge, and hold harmless the Chabad, its employees, agents, and representatives, of and from the Claims, including all liabilities, claims, actions, damages, costs or expenses of any kind arising out of or relating thereto.

By submitting this form, I understand and agree that this release includes any Claims based on the actions, omissions, or negligence of the Chabad, its employees, agents, and representatives, whether a COVID-19 infection occurs before, during, or after participation in any program.

Field Trips:

I hereby give permission to EHA to transport my child in a vehicle and/or allow their participation on field trips. (see handbook for full field trip procedures)

Field Trip Release*

Agree Disagree

List the Name(s) of All Walkers/Biker Riders Walkers and bike riders must be in 2nd grade or older

Emergency Transportation and Treatment Authorization:

In the event I cannot be reached to make arrangements for emergency medical or dental care for my child, I grant permission for my child(ren) to be taken to the nearest hospital or medical/dental facility for treatment for any accident or illness that the School feels needs immediate medical attention.

I accept liability for all expenses incurred.

Emergency Transportation and Treatment Authorization*

Agree Disagree

Late Dismissal Fee

*Each minute you are late will be documented. Chronically tardy parents will be charged $10.00 for the first five (5) minutes and then $2.00 for each consecutive minute. (see handbook for full arrival and dismissal procedures)

Non-Parent Pick Up

If people other than the child’s parents have permission to pick up your child, please complete the form below. In the event of an emergency school closure or other event, your children may be allowed to go with any of the listed people. If for some reason you will not be home, your child will be kept at the home of this designated person.

The School must be notified by 3:15 p.m . when you have made arrangements to have your child picked up by someone other than the parents.

Person(s) who have permission to pick up.

1. Non-Parent Pick Up Name/Phone Number and Address*

2. Non-Parent Pick Up Name/Phone Number and Address

3. Non-Parent Pick Up Name/Phone Number and Address

I have read and understand the arrival/dismissal policy, late dismissal fee, and non-parent pick up policies.*

Yes

Parent/Guardian Electronic Signature*

Time Stamp

Month Day Year

at Hour Minutes

I agree to EHA Policy, Procedures and Terms and Conditions*

Select

2020-21 SCHOOL YEAR IMPORTANT PAYMENT METHOD

Tuition Fees will be auto-drafted on a monthly basis. Auto-draft is a program that will use your bank or credit card provider and automatically make your school payment from your account.

By submitting this registration I agree to all the Terms and Conditions with Esformes Hebrew Academy and acknowledge that I read and understand these conditions as well as the Esformes Handbook. To access please go to our website.

Click HERE to set up your tuition payment information. PLEASE NOTE THAT YOUR CHILD(REN)'S ENROLLMENT IS NOT COMPLETE UNTIL THIS INFORMATION IS ENTERED.

EHA ONLINE ENROLLMENT

Parent Information

Student Information

Medical/Health Information

Emergency Contacts

Parent Waivers/Permission

Tuition Payment Information