ב"ה

Registration

Student Information
Full Name*
First Name Last Name
Hebrew Name
Birth Date*

Month Day Year
School*
Grade entering*
Hebrew Reading Proficiency

NoneSomewhatWell
Previous Jewish Education

YesNo
Where?
Is the natural mother and maternal grandmother of the child Jewish?*

YesNo
Have there been any adoptions or conversions in the family? If yes, please explain.

Home Address*

Parents Information
Father's Name*
First Name Last Name
Father's Cell*

Area Code Phone Number
Father's Email
Mother's Name*
First Name Last Name
Mother's Cell*

Area Code Phone Number
Mother's Email
I am willing to assist in school activities, please contact me
Emergency Information
Emergency Contact 1*
Emergency Contact 2*
Additional notable Information* Please let us know if there are any allergies or other important information we need to be aware of.
Payment
$880 Annual tuition + $50 Book Fee + $50 Security Fee
Discount Code
Registration Fees

$50 Book Fee + $50 Security Fee
Sale

I would like to make a one time payment of $892 ($792 paid-in-full discount, plus $100 registration fees).I would like to pay in eight installments of $110, and pay the $100 registration fees now.
Payment Options

I would like to make a one time payment of $936 ($836 paid-in-full discount, plus $100 registration fees).I would like to pay in eight installments of $110, and pay the $100 registration fees now.
Total

$100.00

Payment

Credit Card

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

As the parent(s) or legal guardian of the above child, I/we authorize any adult acting on behalf of Chabad Hebrew School to hospitalize or secure treatment for my child, I further agree to pay all charges for that care and/or treatment. It is understood that if time and circumstances reasonably permit, Chabad Hebrew School personnel will try, but are not required, to communicate with me prior to such treatment. I hereby give permission for my child to participate in all school activities, join in class and school trips on and beyond school properties and allow my child to be photographed while participating in Chabad Hebrew School activities and that these pictures may be used for marketing purposes.
*

I accept
Name Initials
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