Hebrew School Registration

Number of Children Being Registered*

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*

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 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?*

TRACK 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: $75 Per child
Security Fee: $60 Per family

TRACK 2: Virtual Hebrew School - Ages 5-13
Wednesday Afternoons
Registration Fee: $75 Per child
Supplies Fee $25/month Per child

TRACK 1: Please select the day/s your child will be attending.

Sunday $895 + Reg. & Security FeeMonday $895 + Reg. & Security FeeWednesday $895 + Reg. & Security FeeSunday & Monday $990 + Reg. & Security FeeMonday & Wednesday $990 + Reg. & Security Fee

TRACK 2:

Wednesday $800 + Reg. & Supplies 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

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 2022I 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*

Sponsor a students for a month $100Sponsor a student for 3 months $250Sponsor a students for a year $650I would not like to donate at this timeOther amount?

Other donation amount

$

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 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.

Basic Information

About your child

Emergency Information

Tuition and Dates

Payment Options