Registration for 2025-2026 How many students are you signing up? 123 Student Profile Full Name* First Name Last Name Hebrew Name* First Name Last Name Birth Date* 1 - January2 - February3 - March4 - April5 - May6 - June7 - July8 - August9 - September10 - October11 - November12 - December Month12345678910111213141516171819202122232425262728293031 Day2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 Year Time of day born Please specify AM or PM 123456789101112 Hour001020304050 MinutesAMPM Age at Admission:* Address* Street Address Street Address Line 2 City State / Province Postal / Zip CodePlease SelectUnited StatesAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanThe BahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChilePeople's Republic of ChinaRepublic of ChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCook IslandsCosta RicaCote d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonThe GambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern MarianaNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint BarthelemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSomalilandSouth AfricaSouth OssetiaSpainSri LankaSudanSurinameSvalbardSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTristan da CunhaTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamBritish Virgin IslandsUS Virgin IslandsWallis and FutunaWestern SaharaYemenZambiaZimbabweOther 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* 1 - January2 - February3 - March4 - April5 - May6 - June7 - July8 - August9 - September10 - October11 - November12 - December Month12345678910111213141516171819202122232425262728293031 Day2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 Year Time of day born* Please specify AM or PM 123456789101112 Hour001020304050 MinutesAMPM Age at Admission:* 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 1 - January2 - February3 - March4 - April5 - May6 - June7 - July8 - August9 - September10 - October11 - November12 - December Month12345678910111213141516171819202122232425262728293031 Day2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 Year Time of day born Please specify AM or PM 123456789101112 Hour001020304050 MinutesAMPM Age at Admission: 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* Jewish By BirthJewish By ConversionNot JewishNA Mother* Jewish By BirthJewish By ConversionNot JewishN/A Maternal Grandmother* Jewish By BirthJewish By ConversionNot Jewish 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 2025-2026 tuition for the GEO Jewish After School per child per month is: 2 days - $311 monthly 3 days - $478 monthly 4 days - $575 monthly 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 2025-2026. 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 Paypal Credit Card We accept Visa, MasterCard, American Express, Discover Credit Card Number Security Code Name on Card1 - January2 - February3 - March4 - April5 - May6 - June7 - July8 - August9 - September10 - October11 - November12 - December Expiration Month2025202620272028202920302031203220332034 Expiration YearPaypal has been selected. Payment will take place on the next page.Billing Address Street Address City State / Province Postal / Zip CodePlease SelectUnited StatesAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanThe BahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChilePeople's Republic of ChinaRepublic of ChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCook IslandsCosta RicaCote d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonThe GambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern MarianaNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint BarthelemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSomalilandSouth AfricaSouth OssetiaSpainSri LankaSudanSurinameSvalbardSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTristan da CunhaTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamBritish Virgin IslandsUS Virgin IslandsWallis and FutunaWestern SaharaYemenZambiaZimbabweOther 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 Submit For questions or comments, feel free to contact our GEO Afterschool Director, Chanie Fogelman at [email protected] Should be Empty: This page uses TLS encryption to keep your data secure.
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