Number of Children Being Registered*123Basic InformationStudent's Full Name - 1*First NameLast NameStudent's Hebrew Name*Gender*FemaleMaleBirth Date*MonthDayYear Grade Entering*Student's Full Name - 2First NameLast NameStudent's Hebrew NameGenderFemaleMaleBirth DateMonthDayYear Grade EnteringStudent's Full Name - 3First NameLast NameStudent's Hebrew NameGenderFemaleMaleBirth DateMonthDayYear Grade EnteringHome Address*Street AddressStreet Address Line 2CityState / ProvincePostal / Zip CodePlease SelectUnited StatesAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanThe BahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChilePeople's Republic of ChinaRepublic of ChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCook IslandsCosta RicaCote d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonThe GambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern MarianaNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint BarthelemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSomalilandSouth AfricaSouth OssetiaSpainSri LankaSudanSurinameSvalbardSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTristan da CunhaTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamBritish Virgin IslandsUS Virgin IslandsWallis and FutunaWestern SaharaYemenZambiaZimbabweOtherCountryFather's Full Name*First NameLast NameFather's Cell Phone Number*Area CodePhone NumberMother's Full Name*First NameLast NameMother's Hebrew Name*Mother's Cell Phone Number*Area CodePhone NumberWas the child's mother born Jewish?*YesNoIs the child's father Jewish?*YesNoWas the child's mother's mother born Jewish?*YesNoAre there any adoptions in the family?*YesNoAre there any conversions in the family?*YesNoIf you answered yes to either one please specify:Mother's E-mail*Father's E-mail*Which email would you like us to contact?*MotherFatherBothMarital Status*MarriedSeperatedDivorcedSingle ParentFather DeceasedMother DeceasedI would like to be added to the Hebrew School Whatsapp Group to stay informed of events & updatesYesNoIf you answered yes, Phone Number to add to whatsappArea CodePhone NumberAbout your childPrevious religious school education*Does your child have any learning difficulties with general studies?*YesNoPlease explain:Any behavioral information we should be aware of?*Summer camp your child attends*Emergency InformationEmergency Contact Besides Parent*First NameLast NamePhone Number*Area CodePhone NumberPediatrician*First NameLast NamePhone Number*Area CodePhone NumberMedication 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)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.In the event I need to take my child out of Hebrew School, before January 1st cost will be prorated, after January 1st there will be no refunds. *I have read & agree to all the above.Signature*Date*MonthDayYear How did you hear about our Hebrew School?*Tuition and DatesTRACK 1: In Person Hebrew School - Ages 5-13 Sunday 9:45-11:45 am Mondays: 4:30-6:30 pm Wednesdays: 4:30-6:30 pm Registration Fee: $50 Per child Security Fee: $60 Per familySupplies Fee: $75 Per child TRACK 2: Virtual Hebrew School - Ages 5-13 Wednesday Afternoons Registration Fee: $75 Per child Supplies Fee $40/month Per childTRACK 1: Please select the day/s your child will be attending.Sunday $895 + Reg., Supplies, & Security FeeMonday $895 + Reg., Supplies, & Security FeeWednesday $895 + Reg., Supplies, & Security FeeSunday & Monday $995 + Reg., Supplies, & Security FeeMonday & Wednesday $995 + Reg., Supplies, & Security FeeTRACK 2:Wednesday $895 + Reg. & Supplies FeeDiscount OptionsEarly Bird Registration - $50 off Tuition (Register before July 8th)New Family Discount - $150 off Tuition (1 per family)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 - $200 off Tuition (Can not be combined with other discounts)Name of new family referralPayment OptionsAll registration forms must be submitted with the registration fee and full payment or payment plan.All applications will automatically be charged the $75 Registration fee. I would like to pay the Tuition by: please select.*Full tuition by Credit CardMonthly payments by credit card, through January 2023I will mail in check/s for the remaining balance prior to September 1stI would like to donate to the Chabad Hebrew School Education Scholarship Fund in the amount of*Sponsor a students for a month $100Sponsor a student for 3 months $300Sponsor a students for a year $895I would not like to donate at this timeOther amount?Other donation amount$Total$0.00PaymentCredit CardVisaMasterCardAmerican ExpressDiscoverCredit Card TypeCredit Card NumberSecurity CodeName on Card1 - January2 - February3 - March4 - April5 - May6 - June7 - July8 - August9 - September10 - October11 - November12 - DecemberExpiration Month2022202320242025202620272028202920302031Expiration YearBilling AddressStreet AddressStreet Address Line 2CityState / ProvincePostal / Zip CodePlease SelectUnited StatesAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanThe BahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChilePeople's Republic of ChinaRepublic of ChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCook IslandsCosta RicaCote d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonThe GambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern MarianaNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint BarthelemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSomalilandSouth AfricaSouth OssetiaSpainSri LankaSudanSurinameSvalbardSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTristan da CunhaTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamBritish Virgin IslandsUS Virgin IslandsWallis and FutunaWestern SaharaYemenZambiaZimbabweOtherCountryI would like more information on the following programs:Youth - Gan Israel Day CampPre-Teens - Bar/Bat Mitzvah LessonTeens - Cteen (humanitarian/social program for HS students)Adults - Adult Educatin**YOU WILL BE NOTIFIED VIA EMAIL UPON APPLICATION ACCEPTANCE**Please note: As it takes time for the office to process the forms. All forms must be received no later than August 20th in order for your child to begin Hebrew School on time.SubmitShould be Empty: This page uses TLS encryption to keep your data secure.