Returning Student Registration - Chabad Lubavitch of Western Monmouth County

Family Name
First Name Last Name
Number of children being registered*
Student 1 Name*
First Name Last Name
Student 1 Hebrew Name
Grade Entering*
Birth Date*

Month Day Year
Student 2 Name
First Name Last Name
Student 2 Hebrew Name
Student 2 Grade Entering
Birth Date

Month Day Year
Student 3 Name
First Name Last Name
Student 3 Hebrew Name
Student 3 Grade Entering
Birth Date

Month Day Year
Has any information changed from last year? (Such as address, email, contact info)*

YesNo
If yes please list:
Any comments or suggestions for the coming hebrew school year?
I would like to be added to the Hebrew School Whatsapp Group to stay informed of events & updates

YesNo
If you answered yes, Phone Number to add to whatsapp

Area Code Phone Number
Parent 1 E-mail*
Parent 2 E-mail
Please send all email correspondence to*

Parent 1Parent 2Both

Address

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

Phone Number

Area Code Phone Number
Father's Full Name
First Name Last Name
Father's Cell Phone Number

Area Code Phone Number
Mother's Full Name
First Name Last Name
Mother's Cell Phone Number

Area Code Phone Number
Was the child's mother born Jewish?

YesNo
Is the child's father Jewish?

YesNo
Was the child's mother's mother born Jewish?

YesNo
Are there any adoptions in the family?

YesNo
Are there any conversions in the family?

YesNo
If you answered yes to either one please specify:
Mother's E-mail
Father's E-mail
Which email would you like us to contact?

MotherFatherBoth
Any behavioral information we should be aware of?
Emergency Contact Besides Parent
First Name Last Name
Phone Number

Area Code Phone Number
Pediatrician
First Name Last Name
Phone Number

Area Code Phone Number
Medication child is taking on a regular basis
Any special medical circumstances or allergies
- I authorize Chabad Hebrew School to take my child on school trips. (you will be notified prior to any trips via email &/or Text)

- I authorize Chabad Hebrew School to take pictures/video of my child and use them for publicity purposes (i.e., Brochures, Websites)

- In the event I cannot be reached, I hereby grant permission to the staff of Chabad Hebrew School to treat and/or provide a physician or hospital to give emergency treatment to my child.

- I understand that if I need to withdraw my child from Hebrew School, tuition will be prorated if withdrawal occurs before January 1st. After January 1st, no refunds will be issued.

- I understand that the registration fee is non refundable
*

I have read & agree to all the above.
Signature*
Date*

Month Day Year
Tuition and Dates
Hebrew School - Ages 5-14
Wednesdays 4:30-6:30 pm
Sunday 9:45-11:45 am.
$895 Tuition + $75 Nonrefundable Registration/Book Fee
Dates & Times

Sundays: Ages 5-14
Wednesdays: Ages 6-14

Sundays 9:30-11:30 am
Wednesdays: 4:30-6:30 pm

Registration Fee: $100 Per child
Security Fee: $125 Per family
Please select the day/s your child will be attending.

Sundays $1090 + Reg. & Security FeeWednesdays $1090 + Reg. & Security FeeSunday Morning CteenU (students in grades 7&8) $540
Discount Options

Returning Student Early Bird Registration - $150 off Tuition (Register by May 28th)Refer a new family – $100 discount (can be used to refer 1 family per year)Sibling discount – $100 discount off second childStudents going into 2nd grade or younger - $250 off Tuition (Can not be combined with other discounts)
Name of new family referral
Payment Options
All registration forms must be submitted with the registration fee and full payment or payment plan. Tuition payments will begin processing in August.
All applications will automatically be charged the $100 Registration fee. I would like to make the remaining payment by: Please select.*

Pay in full by credit cardFour payments by credit card. September - DecemberI will mail in check/s for the remaining balance prior to August 28th (if checks are not received the credit card on file will be charged over 4 payments)
We would like to become a Chabad Youth Network Partner Family. By partnering in all of Chabad Youth activities.*

YesNo
Monthly membership/partnership opportunities include a monthly donation of:* Chabad Youth Partner Families receive discounts to Chabad Youth Events & Holiday Packages

$36 Bronze Partnership$72 Silver Partnership$101 Gold Partnership$180 Platinum Partnership
We will begin having security at CHS. Mandatory Security Fund ($50 minimum per family required)

$50$90$180
Total

$0.00

Payment

Credit Card

We accept Visa, MasterCard, American Express, Discover
Credit Card Number	Security Code
Name on Card
Expiration Month	Expiration Year

Billing Address

Street Address

City

State / Province

Postal / Zip Code

Country

I would like more information on the following programs:

Youth - Gan Israel Day CampPre-Teens - Bar/Bat Mitzvah Lesson Pre- Teens Bar/ Bat Mitzvah ClubTeens - Cteen (humanitarian/social program for High School students)Adults - Adult Education
Please note: As it takes time for the office to process the forms. All forms must be received no later than September 1st in order for your child to begin Hebrew School on time.
Should be Empty:

Tuition and Dates

Payment Options

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