Registration Form

Child's Name*

First NameMiddle NameLast Name

Child's Hebrew Name*

Birth Date*

MonthDayYear

School*

Grade entering (fall 2019)*

Previous Jewish Education

Child's Name

First NameMiddle NameLast Name

Child's Hebrew Name

Birth Date

MonthDayYear

School

Grade entering (fall 2019)

Previous Jewish Education

Child's Name

First NameMiddle NameLast Name

Child's Hebrew Name

Birth Date

MonthDayYear

School

Grade entering (fall 2019)

Previous Jewish Education

Father's name*

First NameLast Name

Father's email*

Father's Cellphone*

Area CodePhone Number

Mother's name*

First NameLast Name

Mother's email*

Mother's Cellphone*

Area CodePhone Number

Address*

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Were there any conversions in the family?*

If yes, what is the relation to the student?

Where was the conversion done?

Who performed the conversion?

Emergency contact 1*

First NameLast Name

Phone Number*

Area CodePhone Number

Emergency contact 2

First NameLast Name

Phone Number

Area CodePhone Number

Up to date with vaccinations*

yesno

Date of last tetanus shot*

MonthDayYear

Additional medical concerns

As the parent(s) or legal guardian of the above child, I/we authorize any adult acting on behalf of Chabad Hebrew School 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, Chabad Hebrew School personnel will try, but are not required, to communicate with me prior to such treatment. I hereby give permission for my child to participate in all school activities, join in class and school trips, on and beyond school properties, allow my child to be photographed while participating in Chabad Hebrew School activities, and that these pictures may be used for marketing purposes.

*

I accept

In an effort to keep our Hebrew School fees the lowest in the area we are requesting that all fees be paid at the beginning of the school year, as in prior years. This enables us to save on administrative, stationary, mailing & etc. costs. We can also plan our budget more effectively

You may pay your balance in one sum or submit postdated checks, dated up until April 1, 2020. A credit card can be submitted as well and we can charge it in monthly installments if needed (a Credit Card 2.9 % surcharge will apply). No refunds or credits will be made due to absenteeism.

If you have difficulty with the above, please call our office to coordinate other arrangements.

Registering:*

One Child $1169 - Payment in FullTwo Children - $1169 + $1069 - Payment in fullThree Children - $1169 + $1069 + $1069 - Payment in fullOne Child - Paying deposit now ($400)Two Children - Paying deposit now ($800)Three Children - Paying deposit now ($1200)

Chabad Family Membership (optional)

$960

I will Donate to the Security fund to hire Guards during Hebrew School:

$

Total

$0.00

Payment

Credit Card Check or cash

Postal / Zip Code

Country

Child 1 Information

Child 2 Information

Child 3 Information

Parents' Information

Religious History

Emergency Information

Medical Information (confidential)

Payment

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