Hebrew School Registration

Student's Full Name - 1*

First NameLast Name

Student's Hebrew Name*

Gender*

FemaleMale

Birth Date*

MonthDayYear

Time of Day*

HourMinutes

School*

Grade Entering*

Student's Full Name - 2

First NameLast Name

Student's Hebrew Name

Gender

FemaleMale

Birth Date

MonthDayYear

Time of Day

HourMinutes

School

Grade Entering

Student's Full Name - 3

First NameLast Name

Student's Hebrew Name

Gender

FemaleMale

Birth Date

MonthDayYear

Time of Day

HourMinutes

School

Grade Entering

Address*

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

Phone Number*

Area CodePhone Number

Father's Full Name*

First NameLast Name

Father's Hebrew Name

Father's Name of Employment

Father's Cell Phone Number*

Area CodePhone Number

Mother's Full Name*

First NameLast Name

Mother's Hebrew Name*

Mother's Name of Employment

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

Does your child read basic Hebrew?*

YesNo

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?*

Any special abilities, habits, etc. which you want us to 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

Allergic reactions to medications*

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.

*

I have read & agree to all the above.

Signature*

Date*

MonthDayYear

How did you hear about our Hebrew School?*

Hebrew School - Ages 5-13
Mondays & Wednesdays 4:30-6:30 pm
Sunday 9:45-11:45 am.
$895 Tuition + $75 Nonrefundable Registration/Book Fee

Please select the day/s your child will be attending*

MondayWednesdaySunday

Discount Options

New Family Discount $200 off Tuition (1 per family, cannot be combined with any other discount) )Applications received before July 10th - $75 discount (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 1st grade or younger - $150 discount

Name of new family referral

All applications will automatically be charged the $75 Registration fee. To make additional payments please select.

Full tuition by Credit CardMonthly payments by credit card, through March 2019I will mail in check/s for the remaining balance prior to August 15th

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.

Total

$36.00

I would like to pay today: Full amount$75.00 minimum $

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:

**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 15th in order for your child to begin Hebrew School on time.

Basic Information

About your child

Emergency Information

Tuition and Dates

Payment Options

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