Returning Student Registration

Student's Full Name -*

First NameLast Name

Grade Entering*

Student's Hebrew Name*

Student's Full Name - 2

First NameLast Name

Grade Entering

Student's Hebrew Name

Student's Full Name - 3

First NameLast Name

Grade Entering

Student's Hebrew Name

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

Mother's Full Name*

First NameLast 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

Any behavioral information we should be aware of?*

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.

*

I have read & agree to all the above.

Signature*

Date*

MonthDayYear

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

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 2nd grade or younger - 50% off

Name of new family referral

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

Full tuition by Credit CardMonthly payments by credit card, through March 2020I 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 for families in need in the amount of:*

$36$72$100I would not like to donate at this time.

I would like to donate to the Chabad Hebrew School Education Scholarship Fund for families in need in the amount of:

$36$72$100I would not like to donate at this time.

We will begin having security at CHS. Mandatory Security Fund ($50 minimum per family required)*

$50$90$180

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:

**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.

About Your Child

Emergency Information

Tuition and Dates

Payment Options