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Registration Form

Child 1 Information
Child's Name*
First NameMiddle NameLast Name
Child's Hebrew Name*
Birth Date*
MonthDayYear
School*
Grade entering (fall 2018)*
Previous Jewish Education
Child 2 Information
Child's Name
First NameMiddle NameLast Name
Child's Hebrew Name
Birth Date
MonthDayYear
School
Grade entering (fall 2018)
Previous Jewish Education
Child 3 Information
Child's Name
First NameMiddle NameLast Name
Child's Hebrew Name
Birth Date
MonthDayYear
School
Grade entering (fall 2018)
Previous Jewish Education
Parents' Information
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

Religious History
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 Information
Emergency contact 1*
First NameLast Name
Phone Number*
Area CodePhone Number
Emergency contact 2
First NameLast Name
Phone Number
Area CodePhone Number
Medical Information (confidential)
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
Payment
Tuition charge:
1 child- $1099
Each additional child- $999
A $300 deposit is required per child which is towards tuition.
Payment arrangements can be made by calling our office.
The complete balance is due prior to school opening.
Credit card payments will include a 3% surcharge.
Number of children registering
Amount you will be paying today
$300$600$900$1099$2098$3097
Chabad Family Membership (optional)
$945
Total
$0.00

Payment

Credit Card Check or cash

Postal / Zip Code

Country

Should be Empty:

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