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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 2019)*
Previous Jewish Education
Child 2 Information
Child's Name
First NameMiddle NameLast Name
Child's Hebrew Name
Birth Date
MonthDayYear
School
Grade entering (fall 2019)
Previous Jewish Education
Child 3 Information
Child's Name
First NameMiddle NameLast Name
Child's Hebrew Name
Birth Date
MonthDayYear
School
Grade entering (fall 2019)
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
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

Should be Empty:

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