Contra Costa Midrasha

Contra Costa Midrasha 2011-12 Registration

Thank you for registering for Contra Costa Midrasha's 2011-2012 year.

Here are the 3 easy steps to register for CCM's 2011-12 year!

1. Fill out this electronic form (don't forget to hit the "submit" button at the bottom).

2. Payment Options:
a. CHECK: If you wish to pay by check, once you have submitted this form, a bill will get mailed to you within a week of your submission.
b. ONLINE: If you want to pay online today and in full (with your credit card) visit our online shopping cart at: http://shop.ccmidrasha.com/
c. Payment Plan: If you requested a payment plan in the form below, we will mail you an invoice with the first payment due within a week of your submission.
d. Scholarship/Financial: If you requested a scholarship, or financial aid, we will be contacting you over the phone within a week of your submission.

3. Fill out and return the Medical Information Form to the Contra Costa Midrasha office by the first night your teen joins us for our program. This form will be sent to you upon completion of this form. (In order to comply with HIPAA requirements, medical information is not asked in this electronic form below.)

When you click "submit" at the bottom of this form, you are financially committing to this program. If you have any questions, please contact the CCM office at office@ccmidrasha.com or 925/944-4701. Thank you!

Student Information

Student First Name: *

Student Last Name: *

Student's Grade Next Year (2011-12) at Midrasha: *

Name of Student's School: *

Student's E-mail Address:

If they have one

Student's Cell Phone:

If they have one

Date of Birth: *

Sex: *

Male

Female

Is this teen on Facebook: *

Preferred method of contact: *

E-mail

Texting

Facebook

List one or two friends with whom to share classes and/or a cabin roommate:

Primary Address Information

Home Phone: *

Home Address: *

Home City: *

Home Zip: *

Parent Information

If parents live in separate households, student lives with:

Send mail to:

Parent #1 Information

Last Name: *

First Name: *

Day/Work Phone: *

Cell Phone: *

E-mail Address: *

Parent #2 Information

Last Name:

First Name:

Day/Work Phone:

Cell Phone:

E-mail Address:

If Parent/Guardian II lives in a separate household

Home Phone:

Address:

City:

Zip:

Grandparent Information

Paternal Grandparents

First Name:

Last Name:

Address:

City:

State:

Zip:

Maternal Grandparents

First Name:

Last Name:

Address:

City:

State:

Zip:

Emergency Contact Information

One of the following people will be notified if neither parent can be reached.

Name:

Relationship:

Cell Phone:

Permission & Code of Conduct

By clicking this box, I am providing an electronic signature agreeing to the terms in the Permission & Code of Conduct: *

Yes

Read the Permission & Code of Conduct

Student Understanding

By clicking this box, I am providing an electronic signature agreeing to the terms in the Student Understanding: *

Yes

Read the Student Understanding

Payment Information

Contra Costa Midrasha's tuition cost is $550 for the whole year.

If you are members of one of our partner synagogues (Beth Chaim, B'nai Shalom or B'nai Tikvah), they will pay $150 of your student's tuition fee. This will make your student's tuition fee = $400 for the year.

Retreat package prices for the 2011-12 year are $375 for one retreat, $700 for two retreats and $980 for three retreats.

If you need to request financial aid or a scholarship for your teen, please mark the Financial Aid button at the very bottom of this form. We will mail you a form to fill out. This form is confidential.

Thank you.

Tuition

Please use this form to let us know how you want to pay for Midrasha for the 2011-12 year, even if you are applying for a scholarship and/or financial aid. An invoice reflecting the total amount due will be sent to you within 2 business day of submitting this form, or if we have questions, we will give you a call. If you have questions, please e-mail the Contra Costa Midrasha office at office@ccmidrasha.com or call at 925/944-4701.

I understand the tuition fee: *

Yes

Annual tuition for Contra Costa Midrasha is $550. By registering your teen for the 2010-11 program, this is the base fee. Click this box to indicate you understand this fee.

Synagogue Membership Discount

As a member of one of our community’s synagogues, you get a $150 discount off the tuition fee. Please use the drop-down box to let us know which synagogue you belong to.

Synagogue Membership:

Other:

Please fill in

I understand the Annual Fundraiser Fee: *

Yes

This year, Contra Costa Midrasha is requiring each family purchase two tickets at $48/each ($96 total)* to its annual fundraising event, during the Winter of 2011. This is a tax-deductible donation. Click this box to indicate you understand this fee. *Scholarships for the annual event can also be arranged.

Retreats

Retreats are an integral part of the Midrasha program. Therefore, we highly recommend that teens enrolled in Contra Costa Midrasha attend at least one retreat.

For details about the retreats please visit www.ccmidrasha.com/midrasha-retreat-weekends for information. 8th Grade students can attend the Winter and/or Spring retreats, 9th – 12th grade teens are invited to attend all three retreats in Fall (Dec. 9-11, 2011), Winter (Feb. 3-5, 2012) and Spring (Apr. 20-22, 2012). Please use the drop down box to indicate how many retreats your teen plans on attending in the 2011-12 year.

One Retreat - $375:

Fall (Dec. 9-11, 2011)

Winter (Feb. 3-5, 2012)

Spring (Apr. 20-22, 2012)

Please click which one your teen plans to attend

Two Retreats - $700:

Fall (Dec. 9-11, 2011)

Winter (Feb. 3-5, 2012)

Spring (Apr. 20-22, 2012)

Please click the two retreats your teen plans to attend

Three Retreats - $980:

Please sign up my teen for all three

Not Sure:

We are not currently sure whether or not our teen will attend retreats this year

Synagogue Member Retreat Fee:

YES (We are synagogue members)

NO (We don’t hold a synagogue membership)

If your family is not a member with one of our sponsoring synagogues, CCM will add $45 onto your total retreat bill.

Sibling Discount:

We will deduct $50 for each additional sibling attending Midrasha. (Note: This discount can only be used once per household.)

Summer Payments + Early Bird Discount:

I sent in the pre-registration form before July 1, 2011.

If your registration was submitted before July 1, 2011, subtract $20, plus the additional $125 payment you made at the time. Click here if you sent in the pre-registration form before July 1, 2011.

How to bill our family for 2011-12 at Contra Costa Midrasha:

We will pay in full upon receipt of the bill. (Check or credit cards accepted.)

We will pay in 3 payments (October 2010, December 2010 & February 2011), following an initial *minimum payment of $125 due no later than September 14, 2011.

We need to request financial aid and/or a scholarship. (It is Midrasha’s policy to turn no teen away for lack of funds. By choosing this option, we will send you the Financial Aid/Scholarship Request form. Please fill out this form and return it to Contra Costa Midrasha immediately. Our Executive Director, Devra Aarons, will contact you to confidentially make arrangements.)

*Minimum payment waived if you pre-registered, prior to July 1, 2011

Thank you.:

Thank you for taking the time to fill out this form. Please use the space above to indicate any final questions or comments you might have.

Based on the information in this form, CCM will generate your bill. Or visit our new online shopping cart at http://shop.ccmidrasha.com/ to pay today using your credit card.

If you have any questions upon receiving this initial bill, please contact the CCM office at 925/944-4701 or office@ccmidrasha.com. We look forward to sharing the 2010-11 year with your teen and your family. Shalom!

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CCM is generously supported by its community partners and donors including:

The Jewish Community Federation & Foundation of the East Bay
The Legacy Heritage Fund through Brandeis University's Institute for Informal Jewish Education
Congregations Beth Chaim, B'nai Shalom, and B'nai Tikvah
Sinai Memorial Chapel

Contra Costa Midrasha
74 Eckley Lane
Walnut Creek, CA 94596
office@ccmidrasha.com
(925) 944-4701
(925) 944-4703 Fax
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