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Hebrew School Registration

Basic Information
Student's Full Name - 1*
First NameLast Name
Student's Hebrew Name*
Gender*
FemaleMale
Birth Date*
MonthDayYear
School*
Grade Entering*
Student's Full Name - 2
First NameLast Name
Student's Hebrew Name
Gender
FemaleMale
Birth Date
MonthDayYear
School
Grade Entering

Home Address*

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

Father's Full Name*
First NameLast Name
Father's Cell Phone Number*
Area CodePhone Number
Mother's Full Name*
First NameLast Name
Mother's Hebrew Name*
Mother's Cell Phone Number*
Area CodePhone 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
Marital Status*
MarriedSeperatedDivorcedSingle ParentFather DeceasedMother Deceased
About your child
Previous religious school education*
Does your child have any learning difficulties with general studies?*
YesNo
Please explain:
Any behavioral information we should be aware of?*
Summer camp your child attends*
Emergency Information
Emergency Contact Besides Parent*
First NameLast Name
Phone Number*
Area CodePhone Number
Pediatrician*
First NameLast Name
Phone Number*
Area CodePhone Number
Medication child is taking on a regular basis*
Any special medical circumstances or allergies*
Please send a copy of Immunizations
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 Dates
Hebrew School - Ages 5-13
Sunday 9:45-11:45 am/ 12:00 pm. (Based on Grades)
Wednesdays: 4:30-6:30 pm
Mondays Mitzvah Art Program: 4:30-6:30
Please select the day/s your child will be attending*
Sunday $850 + Reg. & Security FeeWednesday $850 + Reg. & Security FeeMonday Mitzvah Art Program $850 + Reg. & Security FeeSunday & Monday $990 + Reg. & Security FeeMonday & Wednesday $990 + Reg. & Security Fee
Discount Options
Early 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
Name of new family referral
Payment Options
All registration forms must be submitted with the registration fee and full payment or payment plan.
All applications will automatically be charged the $100 Registration fee. To make additional payments please select.*
Full tuition by Credit CardMonthly payments by credit card, through January 2021I will mail in check/s for the remaining balance prior to September 1st
I would like to donate to the Chabad Hebrew School Education Scholarship Fund in the amount of*
$36$72$100I would not like to donate at this time.
We will be having security at CHS. Mandatory Security Fund ($60 minimum per family required)*
$60$90$180- Sponsor a week of security at CHS
Total
$0.00

Payment

Credit Card

Credit Card Type
Credit Card Number	Security Code
Name on Card
Expiration Month	Expiration Year

Billing Address

Street Address

Street Address Line 2

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 LessonPre-Teens/Teens - Cteen Junior (Jewish Club for 7th & 8th graders)Teens - Cteen (humanitarian/social program for HS students)Teens - Friendship Circle - Teen volunteer opportunitiesAdults - Adult EducatinAdults - JBN - Jewish Business NetworkAdults - Synagogue Information
**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.
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Basic Information

About your child

Emergency Information

Tuition and Dates

Payment Options