Registration 2024-2025 old form

Registration for 2024-2025
How many students are you signing up?

123
Student Profile
Full Name*
First Name Last Name
Hebrew Name*
First Name Last Name
Birth Date*

Month Day Year
Time of day born Please specify AM or PM
Hour Minutes
Age at Admission:*

Address*

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

Home Phone Number:*
Primary Language:*
Identifying Marks:*
Eye Color:*
Hair Color:*
Skin Color:*
Sex:*
Height:*
Weight:*
School*
Grade Entering* Grades K -7
Hebrew Reading Proficiency*

WellSomewhatNone
Previous Jewish Education*

YesNo
Where?
Does your child take behavioral medication during regular school hours?*

YesNo
Does your child have any allergies or other medical condition we should be aware of?*

yesno
If yes, please describe and indicate precautions or care needed.
Are there any learning styles which work best for your child? Please detail them here.
Student 2 Profile
Full Name
First Name Last Name
Hebrew Name
First Name Last Name
Gender

MaleFemale
Birth Date

Month Day Year
Time of day born Please specify AM or PM
Hour Minutes
Primary Language:
Identifying Marks:
Eye Color:
Hair Color:
Skin Color:
Sex:
Height:
Weight:
School
Grade Entering Grades K -7
Hebrew Reading Proficiency

WellSomewhatNone
Previous Jewish Education

YesNo
Where?
Does your child take behavioral medication during regular school hours?

YesNo
Does your child have any allergies or other medical condition we should be aware of?

yesno
If yes, please describe and indicate precautions or care needed.
Are there any learning styles which work best for your child? Please detail them here.
Student 3 Profile
Full Name
First Name Last Name
Hebrew Name
First Name Last Name
Gender

MaleFemale
Birth Date

Month Day Year
Time of day born Please specify AM or PM
Hour Minutes
Primary Language:
Identifying Marks:
Eye Color:
Hair Color:
Skin Color:
Sex:
Height:
Weight:
School
Grade Entering Grades K -7
Hebrew Reading Proficiency

WellSomewhatNone
Previous Jewish Education

YesNo
Where?
Does your child take behavioral medication during regular school hours?

YesNo
Does your child have any allergies or other medical condition we should be aware of?

yesno
If yes, please describe and indicate precautions or care needed.
Are there any learning styles which work best for your child? Please detail them here.
Jewish Family Background
Father*
Mother*
Maternal Grandmother*
Were there any adoptions or conversions in the family?*

yesno
If yes, please elaborate
Parent Information
Parent's Name*
First Name Last Name
Relationship to Child:*
Home Address*
Reachable Phone Number:*

Area Code Phone Number
Email Address:*
Business Name:*
Business Address:*
Business Phone Number:*
Hours at Work*
Parent's Name
First Name Last Name
Relationship to Child:
Home Address:
Reachable Phone Number:

Area Code Phone Number
Parent's Email
Business Name:
Business Address:
Business Phone Number:
Home Phone

Area Code Phone Number
Emergency Contact Information
Name*
First Name Last Name
Phone Number*

Area Code Phone Number
Relationship*
Additional Information
Child's physician or medical facility*
Child's Physician Address:*
Phone Number*

Area Code Phone Number
Health Insurance*
Group #*
ID #*
Individual Health Plan for child with a chronic health condition?* If yes, please attach
Copies of any custody agreements, court orders, and restraining orders pertaining to the child? If yes, please attach
Please Attach
Special limitations or concerns?
Terms of Agreement
As the parent(s) or legal guardian of the above child(ren), I/we authorize any adult acting on behalf of GEO Afterschool to hospitalize or secure treatment for my child(ren), I further agree to pay all charges for that care and/or treatment. It is understood that if time and circumstances reasonably permit, GEO Afterschool personnel will try, but are not required, to communicate with me prior to such treatment.
Medical care permissions*

I Agree
I hereby give permission for my child(ren) to participate in all school activities, join in class and school trip on and beyond school properties - including to be transported to and from field trips.
Permission for activities*

I Agree
I allow my child to be photographed during GEO Afterschool. I understand that these photos may be used in publications and/or on social media.
Permission for photos*

I Agree
Initial Here:
I certify that documentation of physical examination and immunizations in accordance with public school health requirements and lead poisoning screening in accordance with public health requirements are on file at my child’s school.
Child's school* Please check all applicable

BrownBen-HemLiljaKennedyMemorial
Initial Here:*
Payment Information
The 2024-2025 tuition for the GEO Jewish After School per child per month is:

2 days - $305
3 days - $470
4 days - $565

Please note that there is a nominal additional fee for students signed up for early release days. Details on the information page.

For Transportation from Ben Hem and Lilja the cost will be $100 per month (subsided)

Discounts:

Siblings: 10% off regular tuition for each additional child. (This applies to regular GEO tuition, not other programs.)

Referral: There is an additional $50 discount off your child's tuition (for the year which will be deducted from your tuition over 2 months) for each new family successfully introduced to GEO Jewish After School.
Please use this comment box if there's anything to explain about tuition otherwise leave blank
Tuition options Monthly tuition for 2024-2025. Includes 10% discount here per addtl. sibling. This payment is your non-refundable deposit which goes towards the last month of the school year. After this registration is submitted you are entered into the billing system for future payments.

1 Child, 2 days1 Child, 3 days1 Child, 4 days2 Siblings, 2 days2 Siblings, 3 days2 Siblings, 4 days3 Siblings, 2 days3 Siblings, 3 days3 Siblings, 4 daysClear
Days of Week Please check all that apply

MondayTuesdayWednesdayThursday
Transportation options from Ben Hem / Lilja*

My child needs transportation - $100 per monthMy child doesn't need transportation
Tuition 2024 - Hidden Section Please choose "Other" if it's anything different than tuition for 1-3 siblings and fill in the correct amount

1 Child, 2 days ($295)1 Child, 3 days ($440)1 Child, 4 days ($535)2 Siblings, 2 days (Sibling Discount -10% - $590 - $29.50) ($560.50)2 Siblings, 3 days (Sibling Discount -10% - $880 - $44) ($836)2 Siblings, 4 days (Sibling Discount -10% - $1070 - $53.50) ($1016.50)3 Siblings, 2 days (Sibling Discount - 10% addtl. child $885 - $59) ($826)3 Siblings, 3 days (Sibling Discount - 10% addtl. child $1320 - $88) ($1218)3 Siblings, 4 days (Sibling Discount - 10% addtl. child $1605 - $107) ($1498)
Tuition amount

$0.00 USD

Payment

Credit Card eCheck Check

Postal / Zip Code

Country

How did you hear about GEO Jewish After School?
By Checking this box I'm electronically signing that I've read the parent handbook* handbook can be found at "Apply Now" page

yes, I have read the parents handbook
I would like to receive news and updates by email
For questions or comments, feel free to contact our GEO Afterschool Director, Chanie Fogelman at education@ChabadNatick.com
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