Form Test

Wisdom Garden Registration 2023-24, Grade 3-5

"*" indicates required fields

Student

Student's name*

First Last

Hebrew name (if they have one)

Hebrew name

Grade*

Birthdate*

Allergies

Parent 1

Name – Parent 1*

First Last

Address – Parent 1*

Address City State ZIP / Postal Code

Cell Phone – Parent 1*

Email – Parent -1*

Preferred Means of communication: please check one or both*

Text

Parent 2

Name – Parent 2

First Last

Address – Parent 2

Address City State ZIP / Postal Code

Cell Phone – Parent 2

Email – Parent -2

Preferred Means of communication: please check one or both

Text

Emergency Contact

Name – Emergency Contact 1*

First Last

Relationship*

Phone

Name – Emergency Contact 2*

First Last

Relationship*

Phone*

Tuition

3-5 Tuition is $200.

Hidden

Tuition*

Hidden

Schoarship Fund Donation

Hidden

Total Check Amount*

Hidden

Proposed Payment Date*

No one turned away for financial reasons. Please call Ayala at 541-292-0805 if you need to make financial arrangements.

Please remit to the Havurah office, or mail in to:

Havurah Synagogue
P.O. Box 1262
Ashland, OR 97520

Or email to:
Ayala@ashlandhavurah.org

Phone

This field is for validation purposes and should be left unchanged.