Apply – Mesivta Lubavitch Toronto

Yeshivas Kayitz Application - 5776

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
Supported Credit Cards: 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: