Apply – Mesivta Lubavitch Toronto

Name*

First Last

Address*

Street Address City State / Province / Region ZIP / Postal Code Country

Home Phone Number*

Summer Phone Number

Fax

Father's Cell Phone

Mother's Cell Phone

Father's Email*

Mother's Email

Name of Yeshiva Presently Attending*

Grade*

Rebbe's name*

Emergency and Contact Information

Do you have any allergies or medical issues we should be aware of?*

No
Yes

If yes, please specify:

Name of Physician*

Physician's Phone Number*

Emergency Contact Name*

Emergency Contact Phone Number*

Relation to Student*

O.H.I.P. / Medicaid number (Including verification code)

Private Insurance Coverage: Name of Insurer:

Policy Number:

Authorization:

I/We affirm that all of the above information is accurate. By signing below I/We agree to abide by all the rules of Mesivta Lubavitch Toronto. I/We authorize the school to take our child on official school trips and special activities. In case of emergency I/We authorize Mesivta Lubavitch Toronto to act on our behalf.

Signature of Applicant (Student)*

Please enter your full name, followed by the date

Signature of Guardian

Please enter your full name, followed by the date

Cost:

Cost: The cost for the summer program is $1,650.00. Early bird: A $200.00 discount will be applied to all applications accompanied with full payment by the 9th of Sivan (June 15, 2016).

Product Name

Total

$0.00

Parent Email

Parent's Country of Residence

Credit Card*

MasterCard

Visa

Card Number Expiration Date Security Code Cardholder Name

Billing Address on Credit Card*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Yeshivas Kayitz Application - 5776

Emergency and Contact Information

Authorization:

Cost: