Fauquier Jewish Congregation

Religious School Registration

2017-2018

 

Student #1 Name:  __________________________             Age: ________________

 

Date of Birth: ______________                                              Gender:  M   F            

 

Name of Secular School: _______________________         Grade: ____________

 

Years of Religious School Instruction: _________                  Hebrew Name: ___________________

 

Allergies ____________________________             Medications______________________

 

 

Student #2 Name:__ _________________________  Age: ________________

 

Date of Birth: ______________                                   Gender:  M   F           

 

Name of Secular School: ______________________Grade: ____________

 

Years of Religious School Instruction: ___________ Hebrew Name: ___________________

 

Allergies _____________________________           Medications: _________________________

 

[For additional children write on back]

 

Mother’s Name: ________________________           Father’s Name:________________________

Mother’s Cell:    _________________________         Father’s Cell: _________________________

Home Phone:    ________________________           Home Phone: _________________________

E-mail:              _________________________         E-mail:            _________________________

Address:  ___________________________               Address:  ____________________________

                 ___________________________                          ____________________________

 

Describe any learning issues we should know about?  Please write on back of page. 

 

 

Child 1: ____________________       Description: ___________________________________________

 

Child 2: ____________________       Description: ___________________________________________

 

 

 

       FEES: First Child  $200     Additional Children: $100

 

Please make checks payable to: Fauquier Jewish Congregation

c/o Susan Webster, 103 W. Washington Street

Remington VA 22734


 If you need a financial adjustment or have any questions, please contact: 

Susan Webster tel. 540-229-6233