Hebrew School Registration

Number of Children Being Registered*
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	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
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.

I understand that 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
Sunday: Ages 5-13
Monday & Wednesdays: Ages 6-13

Sunday 9:45-11:45 am
Mondays: 4:30-6:30 pm
Wednesdays: 4:30-6:30 pm
Registration Fee: $100 Per child
Security Fee: $90 Per family
Supplies Fee: $80 Per child
Please select the day/s your child will be attending.

Sunday $990 + Reg., Supplies, & Security FeeMonday $990 + Reg., Supplies, & Security FeeWednesday $990 + Reg., Supplies, & Security FeeSunday & Monday $1090 + Reg., Supplies, & Security FeeMonday & Wednesday $1090 + 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 - $250 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. Tuition payments will begin processing in August.
All applications will automatically be charged the $100 Registration fee. I would like to pay the Tuition by: please select.*

Full tuition by Credit CardQuarterly payments by credit card.I will mail in check/s for the remaining balance prior to August 15th. Checks not received will be charged via CC quarterly.
We would like to become a Chabad Youth Network Partner Family. By partnering in all of Chabad Youth activities.*

Yes - Please choose an option below.No
Monthly membership/partnership opportunities include a monthly donation of: Chabad Youth Partner Families receive discounts to Chabad Youth Events & Holiday Packages

$36 Bronze Partner$101 Silver Partner$180 Gold Partner$250 Platinum Partner$360 Diamond Partner
Total

$0.00

Payment

Credit Card

We accept Visa, MasterCard, American Express, Discover
Credit Card Number	Security Code
Name on Card
Expiration Month	Expiration Year

Billing Address

Street Address

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 Lesson & CTeen Jr.Teens - Cteen (humanitarian/social program for HS students)Adults - Adult Educatin
Please note: As it takes time for the office to process the forms. All forms must be received no later than September 5th in order for your child to begin Hebrew School on time.
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Educate Your Child... Educate a Generation

Basic Information

About your child

Emergency Information

Tuition and Dates

Payment Options

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