1. The Student 

Legal name  
Jewish name  
Email (If the child has)  
Ohip #  
School name  
Grade entering  
Date of Birth
(The time will confirm the correct Jewish birthday)


2. The Parents

  Father Mother
Legal name  


Jewish name  
Work phone  
(if different)

 Has there been a conversion in the family?  Yes No
If yes, please specify whom, and under which Rabbinate 

3. Previous Jewish Education

Does your child read Hebrew?
Deas your child speak/understand Hebrew?
Does your child have any learning difficulties with general studies? 
If yes, please describe: 


Child’s previous Hebrew education, if any:

4. Other

Emergency Contact 1
Emergency Contact 2
Are there any adoptions in the family?  
Are there any conversions in the family?  
If yes, Please complete the conversion form  

5. Tuition: $125/session
    (+$35 supllies & Textbooks) 
* $35 will be added to the first payment for supplies and textbooks
** It is our goal to ensure a formal Jewish education for every Jewish child in the Niagara Region. Every child deserves the gift of his own Heritage, regardless of his/her parents financial abilities. Please contact Rabbi Zalman or Perla personally to discuss payment plans, scholarship or discounts. 

Schedule of payment  
Method of payment  
Card number  
Exp date   

CONFIDENTIAL: Does your child have any allergies or other medical condition we should be aware of?  If yes, please describe them and indicate special precautions or care needed. 


As the parent(s) or legal guardian of the above child, I/we authorize any adult acting on behalf of Aleph Champ Niagara to hospitalize or secure treatment for my child, I further agree to pay all charges for that care and/or treatment. It is understood that if time and circumstances reasonably permit, Aleph Champ Niagara personnel will try, but are not required, to communicate with me prior to such treatment. I hereby give permission for my child to participate in all school activities, join in class and school trips on and beyond school properties and allow my child to be photographed while participating in Aleph Champ activities and that these pictures may be used for marketing purposes. I Accept

Name (Signature)