Family NameFirst NameLast NameNumber of children being registered*123Student 1 Name*First NameLast NameStudent 1 Hebrew NameGrade Entering*Birth Date*1 - January2 - February3 - March4 - April5 - May6 - June7 - July8 - August9 - September10 - October11 - November12 - DecemberMonth12345678910111213141516171819202122232425262728293031Day2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920YearStudent 2 NameFirst NameLast NameStudent 2 Hebrew NameStudent 2 Grade EnteringBirth Date1 - January2 - February3 - March4 - April5 - May6 - June7 - July8 - August9 - September10 - October11 - November12 - DecemberMonth12345678910111213141516171819202122232425262728293031Day2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920YearStudent 3 NameFirst NameLast NameStudent 3 Hebrew NameStudent 3 Grade EnteringBirth Date1 - January2 - February3 - March4 - April5 - May6 - June7 - July8 - August9 - September10 - October11 - November12 - DecemberMonth12345678910111213141516171819202122232425262728293031Day2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920YearHas any information changed from last year? (Such as address, email, contact info)*YesNoIf yes please list:Any comments or suggestions for the coming hebrew school year?I would like to be added to the Hebrew School Whatsapp Group to stay informed of events & updatesYesNoIf you answered yes, Phone Number to add to whatsappArea CodePhone NumberAddressStreet AddressStreet Address Line 2CityState / ProvincePostal / Zip CodePlease SelectUnited StatesAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanThe BahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChilePeople's Republic of ChinaRepublic of ChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCook IslandsCosta RicaCote d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonThe GambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern MarianaNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint BarthelemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSomalilandSouth AfricaSouth OssetiaSpainSri LankaSudanSurinameSvalbardSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTristan da CunhaTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamBritish Virgin IslandsUS Virgin IslandsWallis and FutunaWestern SaharaYemenZambiaZimbabweOtherCountryPhone NumberArea CodePhone NumberFather's Full NameFirst NameLast NameFather's Cell Phone NumberArea CodePhone NumberMother's Full NameFirst NameLast NameMother's Cell Phone NumberArea CodePhone NumberWas the child's mother born Jewish?YesNoIs the child's father Jewish?YesNoWas the child's mother's mother born Jewish?YesNoAre there any adoptions in the family?YesNoAre there any conversions in the family?YesNoIf you answered yes to either one please specify:Mother's E-mailFather's E-mailWhich email would you like us to contact?MotherFatherBothAny behavioral information we should be aware of?Emergency Contact Besides ParentFirst NameLast NamePhone NumberArea CodePhone NumberPediatricianFirst NameLast NamePhone NumberArea CodePhone NumberMedication child is taking on a regular basisAny 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 have read & agree to all the above.Signature*Date*MonthDayYear Tuition and DatesHebrew School - Ages 5-13 Mondays & Wednesdays 4:30-6:30 pm Sunday 9:45-11:45 am. $895 Tuition + $75 Nonrefundable Registration/Book FeeDates & TimesTRACK 1: In Person Hebrew School - Ages 5-13 Sunday 9:45-11:45 amMondays 4:30-6:30 pm Wednesdays: 4:30-6:30 pm Registration Fee: $50 Per child Security Fee: $60 Per family Supplies & Book Fee: $75 Per ChildTRACK 2: Virtual Hebrew School - Ages 5-13 Wednesday afternoonsRegistration Fee: $50 Per child Supplies & Delivery Fee: $40/month Per childTRACK 1: Please select the day/s your child will be attending.Sunday $895 + Reg., Supplies, & Security FeeWednesday $895 + Reg., Supplies, & Security FeeMonday $895 + Reg., Supplies, & Security FeeSunday & Monday $995 + Reg., Supplies, & Security FeeMonday & Wednesday $995 + Reg., Supplies, & Security FeeTRACK 2: VirtualWednesday $895 + Reg. & Supplies FeeDiscount OptionsReturning Student Early Bird Registration - $75 off Tuition (Register before July 8th)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 referralPayment OptionsAll registration forms must be submitted with the registration fee and full payment or payment plan.All applications will automatically be charged the $50 Registration fee. I would like to make the remaining payment by: Please select.*Pay in full by credit cardMonthly payments by credit card, through January 2023I will mail in check/s for the remaining balance prior to August 1stI would like to donate to the Hebrew School education scholarship fund:Sponsor a student for a month $100Sponsor a student for 3 months $300Sponsor a students for a year $895I would not like to donate at this time.Other amount:$We will begin having security at CHS. Mandatory Security Fund ($50 minimum per family required)$50$90$180Total$0.00PaymentCredit CardVisaMasterCardAmerican ExpressDiscoverCredit Card TypeCredit Card NumberSecurity CodeName on Card1 - January2 - February3 - March4 - April5 - May6 - June7 - July8 - August9 - September10 - October11 - November12 - DecemberExpiration Month2022202320242025202620272028202920302031Expiration YearBilling AddressStreet AddressStreet Address Line 2CityState / ProvincePostal / Zip CodePlease SelectUnited StatesAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanThe BahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChilePeople's Republic of ChinaRepublic of ChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCook IslandsCosta RicaCote d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonThe GambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern MarianaNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint BarthelemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSomalilandSouth AfricaSouth OssetiaSpainSri LankaSudanSurinameSvalbardSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTristan da CunhaTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamBritish Virgin IslandsUS Virgin IslandsWallis and FutunaWestern SaharaYemenZambiaZimbabweOtherCountryI would like more information on the following programs:Youth - Gan Israel Day CampPre-Teens - Bar/Bat Mitzvah Lesson Pre- Teens Bar/ Bat Mitzvah ClubPre-Teens/Teens - Cteen Junior (Jewish Club for 7th & 8th graders)Teens - Cteen (humanitarian/social program for HS students)Teens - JLI Teens/Hebrew HighTeens - Friendship Circle - Teen volunteer opportunitiesAdults - Adult EducationAdults - JBN - Jewish Business NetworkAdults - Smiling on SeniorsAdults - Synagogue InformationAdults - JWC - Jewish Women's Circle**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.SubmitShould be Empty: This page uses TLS encryption to keep your data secure.