I would like to enter the Spirit of Sinai Scholarship Raffle.

Student Information: 

Child's Name:    

Hebrew Name: 

Birthdate:

 I would like to attend the Learning & Living Experience $625/year

Does your child read basic Hebrew?  Yes     No

If yes:  Good     Fair     Poor

What school does your child attend?

Is the natural mother of the child Jewish?  Yes     No

Were there any conversions or adoptions in your family?  Yes  No

If yes please describe:

Additional comments: 

Parent Information: 

Father's Name:  

Mother's Name: 

Address:

City, State, Zip 

Phone Number: 

Cell Number: 

Email Address: 

Occupation: 

Emergency Contact Information: 

Name: 

Phone Number: 

Cell Number:  

Doctor Name:  

Doctor Address: 

Doctor Phone Number 

Allergies or Medical Condition: 

As the parent or legal guardian of , I authorize any adult acting on behalf of the Spirit of Sinai Hebrew School to hospitalize or secure treatment for my child in the event of an emergency. I further agree to pay all charges for that care and/or treatment. It is understood that if time and circumstances reasonably permit, Spirit of Sinai Hebrew School personnel will try, but are not required, to communicate with me prior to such treatment. 

I hereby give permission for my child to attend all field trips and outings sponsored by Spirit of Sinai Hebrew School.

I hereby give permission for my child to be photographed during Hebrew School as well as permission to use the photographs in advertising.

Please charge my credit card for the full tuition including registration fees. 

 Please charge my credit card a one time $30 registration fee and $156.25 monthly. (Oct., Nov., Dec., Jan.)

 I will mail a check.

Parent Signature: