GROW Registration Returning Children

1. Child/ren’s Information
Number of children being registered:*
Child 1*

Name Hebrew Name Last Name
Birth Date*

Month Day Year
Time of birth:*

AMPM
Child 2*

Name Hebrew Name Last Name
Birth Date*

Month Day Year
Time of birth:*

AMPM
Child 3*

First Name Hebrew Name Last Name
Birth Date*

Month Day Year
Time of birth:*

AMPM
2. Parent information
Mother's info

First Name Last Name
E-mail* Primary email
Cell Phone

Area Code Phone Number
Father's info

First Name Last Name
E-mail
Cell Phone

Area Code Phone Number
What goals do you have for your child attending GROW?
3. Emergency Information
Emergency Contact*

First Name Last Name
Phone Number*

Area Code Phone Number
Doctors Name*

First Name Last Name
Doctors Phone Number*

Area Code Phone Number
Does your child(ren) have any allergies or medical conditions.*

If yes please specify which child and what they are.
Permission for emergency medical treatment*

As the parent or legal guardian, I authorize any adult acting on behalf of GROW 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, Grow personnel will try, but are not required, to communicate with me prior to such treatment.
4. Payment Information
The tuition for GROW is $610.00 per year per child (this does not include $50 registration & book fee). For members it is discounted to $410. Family discount (5% off additional children, for members and non-members). Scholarships available.

For more information about scholarships or for assistance with a financial plan, please contact Rabbi Pinchas Adler 727 631 7398.
Payment Options*

Plan A: I will pay the entire amount in full.To do so, please submit a check or include your credit card information below.Plan B: I will pay the annual tuition on a monthly basis by check. I will send in checks of $76.25 each (Members $51.25), September through April. All checks must be submitted on the first GROW of the month. This is in addition to the registration/book fee of $50 due at sign up.Plan C: I will pay the annual tuition on a monthly basis by credit card. This is in addition to the registration/book fee of $50 due at sign up. Your card will be billed $76.25 monthly (Members $51.25) September through April. To do so please include your credit card number and expiration date at the bottom of this page. Credit cards will be charged on the first of the month unless otherwise indicated.Payment plan discussed with Rabbi Pinchas.

Payment*

Credit Card Check

Agreement*

I am signing up my child for GROW. Please charge my card the registration fee or send me a invoice today. I give permission to GROW to photograph and videotape my children and use the photos and videos for advertising purposes.
Please share any other information you feel is important for GROW to be aware of. This can include exceptional behavior, concerns, particular activities, family relationships etc.
Should be Empty:

1. Child/ren’s Information

2. Parent information

3. Emergency Information

4. Payment Information

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