Gan Chabad | Application for School Year 2021-2022

Child Information

Child's Name(Required)

First Last

Hebrew Name(Required)

Birthday(Required)

Main Phone(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

Parent Information

Father's Name(Required)

Mother's Name(Required)

Father's Cell Phone(Required)

Mother's Cell Phone(Required)

Father's Email(Required)

Mother's Email(Required)

Best way to contact father(Required)

Best way to contact mother(Required)

Emergency Contacts

Name(Required)

Phone(Required)

Relationship(Required)

Name(Required)

Phone(Required)

Relationship(Required)

Medical Information

Is your child up to date with vaccines?(Required)

Yes

No

If not, please attach letter from pediatrician.

Accepted file types: pdf, jpg, png, doc, Max. file size: 512 MB.

Does your child have any food or other allergies (including medication)?(Required)

Is there any special medical or other information that we should know about? Please include all relevant information.(Required)

Pediatrician's Name(Required)

First Last

Pediatrician's Phone(Required)

Medical Insurance Company(Required)

Policy Number(Required)

Pick-Up Authorization

Name(Required)

Phone(Required)

Relationship(Required)

Name(Required)

Phone(Required)

Relationship(Required)

Name(Required)

Phone(Required)

Relationship(Required)

Full Time Pre-School through PHL Pre-K with our added Judaic Programming: $1000 annually ($100/month on a 10 month Payment Plan) (8:30- 3:30 pm) Children wo are 3 or 4 (By September1st) and who meet the criteria will be approved for PRE-K through the PHL Program. We will need proof of address and a copy of the child's birth certificate to determine eligibility

Full time Toddler (12-36 months): $6,150 ($615/month on a 10 month Payment Plan) 8:30-3:30 Full time

Infant (up to 12 months): $7,150 ($715/month on a 10 month Payment Plan) 8:30-3:30

Extendedcare: Care is available from 7:30-5:30pm for an additional flat fee of $165 a month. Extended Care covers 7:30-8:30 AM and 3:30-5:30PM. This does not include Fridays.

Meal Program: Breakfast, Lunch & Snack will be provided to your child at no extra cost.

To secure a place for your child in our program, please complete this form together with a non-refundable deposit in the amount of $100* and indicate below: (May check more than 1 if it applies)

I would like to sign my child up for the Infant room program for $7,150 annual tuition from the hours of 8:30 - 3:30

I would like to sign my child up for the Toddler room program for $6,150 annual tuition from the hours of 8:30 - 3:30

I would like to sign my child up for the PreK program for $1000 annually from the hours of 8:30 - 3:30

I would like to sign my child up for FULL extended care (7:30 - 8:30/ 3:30 - 5:30) for an additional $165 per month per child.

I would like to sign my child up for early care (7:30am - 8:30am) for an additional $60 per month per child.

I would like to sign my child up for partial late care (3:30pm - 4:30pm) for an additional $60 per month per child.

I would like to sign my child up for partial late care (3:30pm - 5:30pm) for an additional $120 per month per child.

I'm a CCIS resident. My weekly copay is: ($)

Registration Fee

Price:

*Registration Fee is per child, is nonrefundable, is exclusive of tuition and is necessary for us to hold a spot for your child.

I hereby permit my child to participate in all school activities and join in school trips beyond the premises. I hereby consent to The Gan staff to take whatever medical measures they deem necessary, at my expense, for my child in the event of a medical emergency.

I also(Required)

do

do not

grant permission for my child to be photographed for promotional purposes.

Parent's Signature(Required)

Date(Required)

Parent's Signature(Required)

Date(Required)

Total

Payment Method*

American Express

Discover

MasterCard

Visa

Card Number Expiration Date Security Code Cardholder Name

Billing Address(Required)

Street Address Address Line 2 City State ZIP Code

Application for School Year 2021-2022

Child Information

Parent Information

Emergency Contacts

Medical Information

Pick-Up Authorization

Get In Touch

(215) 695-0399