Number of Children Being Registered* 1 2 3 Basic Information Student's Full Name - 1* First Name Last Name Student's Hebrew Name* Gender* FemaleMale Birth Date* Month Day Year Grade Entering* Student's Full Name - 2 First Name Last Name Student's Hebrew Name Gender FemaleMale Birth Date Month Day Year Grade Entering Student's Full Name - 3 First Name Last Name Student's Hebrew Name Gender FemaleMale Birth Date Month Day Year Grade Entering Home Address* Street Address Street Address Line 2 City State / Province Postal / Zip Code Please Select United States Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan The Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Brazil Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile People's Republic of China Republic of China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Cote d'Ivoire Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Eswatini Ethiopia Falkland Islands Faroe Islands Fiji Finland France French Polynesia Gabon The Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati North Korea South Korea Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Islands Poland Portugal Puerto Rico Qatar Romania Russia Rwanda Saint Barthelemy Saint Helena Saint Kitts and Nevis Saint Lucia Saint Martin Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia Somaliland South Africa South Ossetia Spain Sri Lanka Sudan Suriname Svalbard Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tristan da Cunha Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam British Virgin Islands US Virgin Islands Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe Other Country 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 Hebrew 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 Marital Status* MarriedSeperatedDivorcedSingle ParentFather DeceasedMother Deceased 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 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 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) 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* Month Day Year How did you hear about our Hebrew School?* Tuition and Dates 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: $90 Per family Supplies Fee: $100 Per child 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 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 (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. All applications will automatically be charged the $100 Registration fee. I would like to pay the Tuition by: please select.* Full tuition by Credit CardMonthly payments by credit card, through January 2024I 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 $300Sponsor a students for a year $895I would not like to donate at this timeOther amount? Other donation amount $ Total $0.00 Payment Credit Card We accept Visa, MasterCard, American Express, Discover Credit Card Number Security Code Name on Card 1 - January 2 - February 3 - March 4 - April 5 - May 6 - June 7 - July 8 - August 9 - September 10 - October 11 - November 12 - December Expiration Month 2023 2024 2025 2026 2027 2028 2029 2030 2031 2032 Expiration Year Billing Address Street Address Street Address Line 2 City State / Province Postal / Zip Code Please Select United States Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan The Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Brazil Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile People's Republic of China Republic of China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Cote d'Ivoire Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Eswatini Ethiopia Falkland Islands Faroe Islands Fiji Finland France French Polynesia Gabon The Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati North Korea South Korea Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Islands Poland Portugal Puerto Rico Qatar Romania Russia Rwanda Saint Barthelemy Saint Helena Saint Kitts and Nevis Saint Lucia Saint Martin Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia Somaliland South Africa South Ossetia Spain Sri Lanka Sudan Suriname Svalbard Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tristan da Cunha Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam British Virgin Islands US Virgin Islands Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe Other 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 September 1st in order for your child to begin Hebrew School on time. Submit Should be Empty: This page uses TLS encryption to keep your data secure.