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:
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 or 925/944-4701. Thank you!

Student Information

If they have one

If they have one

Primary Address Information
Parent Information
Parent #1 Information
Parent #2 Information
Emergency Contact Information

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

Permission & Code of Conduct
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.


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 or call at 925/944-4701.

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.

Please fill in

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 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 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.

Please click which one your teen plans to attend

Please click the two retreats your teen plans to attend

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

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

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.

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

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 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 We look forward to sharing the 2010-11 year with your teen and your family. Shalom!