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Chabad Hebrew School

Inspiring Jewish Pride and Identity in Jewish Children - the future of Judaism.

ב"ה

Post Bar/Bat Mitzvah Program

Basic Information
Student's Full Name*
First NameLast Name
Student's Hebrew Name*
Gender*
FemaleMale
Birth Date*
MonthDayYear
Grade Entering:*
7th8th
School*

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 Cell Phone Number*
Area CodePhone Number
Father's E-mail:*
Mother's Full Name*
First NameLast Name
Mother's Cell Phone Number*
Area CodePhone Number
Mother's E-mail:
Is the child's mother born Jewish?*
YesNo
Mother's Hebrew Name:*
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:
About your child
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?*
Emergency Information
Emergency Contact 1*
First NameLast Name
Phone Number*
Area CodePhone Number
Emergency Contact 2
First NameLast Name
Phone Number
Area CodePhone Number
Medication child is taking on a regular basis*
Any special medical circumstances or allergies*
Tuition & Payment Options:
CTeen Junior takes place on Sunday Mornings 10:15-11:45
$600 Tuition
Payment Options:*
Pay in Full: $6002 Equal Payments: $3004 Equal Payments: $150
Amount to charge my card today:*
$
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 authorize the Chabad staff to take my child on class trips (you will be notified prior to any trips).I authorize Chabad staff to take pictures / videos of my child and be able to use them for publicity purposeIn the event I can not be reached I hearby grant permission to the Chabad staff to treat and or provide a physician or hospital to give emergency treatment to my child.
Signature*
Date*
MonthDayYear
Should be Empty:

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