Register

Family Information
Family Name*

Address*

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Home

Area Code Phone Number
Father's Name*
Father's Hebrew Name If available
Father's Email
Father's Cell

Area Code Phone Number
Father's Religion*

Jewish by BirthJewish by ChoiceOther
Father's Parents Religion

Father's Father Jewish by BirthFather's Father Jewish by ChoiceFather's Mother Jewish by BirthFather's Mother Jewish by Choice
Mother's Name*
Mother's Hebrew Name If available
Mother's Email
Mother's Cell

Area Code Phone Number
Mother's Religion*

Jewish by BirthJewish by ChoiceOther
Mother's Parents Religion

Mother's Father Jewish by BirthMother's Father Jewish by ChoiceMother's Mother Jewish by BirthMother's Mother Jewish by Choice
Parents' Marital Status
Does someone other than the parent(s) care for your child(ren)? If yes, please give name and phone number
Child's Information
No. of Children Being Registered*
Child 1
Name*
Hebrew Name If available
Birth Date*

Month Day Year
Time of birth*
School Attending*
Grade Entering*
Placement in Family*
Allergies or medications
Does your child have any medical, developmental or behavioral issue that we should know about? Describe:
Child 2
Name
Hebrew Name
Birth Date

Month Day Year
Time of birth
School Attending
Grade Entering
Placement in Family
Allergies or medications
Does your child have any medical, developmental or behavioral issue that we should know about? Describe:
Child 3
Name
Hebrew Name
Birth Date

Month Day Year
Time of birth
School Attending
Grade Entering
Placement in Family
Allergies or medications
Does your child have any medical, developmental or behavioral issue that we should know about? Describe:
Child 4
Name
Hebrew Name
Birth Date

Month Day Year
Time of birth
School Attending
Grade Entering
Placement in Family
Allergies or medications
Does your child have any medical, developmental or behavioral issue that we should know about? Describe:
Please name/age siblings who are not being enrolled in the Hebrew School this year
Tuition & Payment
Tuition for the school year is $700 per child including registration and book fee.

At Chabad we are committed to providing a Jewish education for every Jewish child. If other payment arrangements are necessary, please call us and us will be happy to help.
Installments*

Pay in full before SeptemberTwo installments to be paid in Sept. 1 and Jan. 1Ten postdated checks due in SeptemberOther (subject to approval)

Payment*

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Postal / Zip Code

Country

Enrollment Agreement
I understand that my registration will be reviewed upon receipt and is subject to approval in writing (via email). Upon acceptance, I agree to pay the tuition fee according to the terms of agreement outlined above.

In the event of an emergency, Chabad Hebrew School has my permission to arrange for any necessary first-aid or care by a licensed physician/first-aid worker. Chabad Hebrew School has my permission to use my child's photo in its publicity materials. I give permission for my child/ren to attend all field trips and outings sponsored by Chabad Hebrew School.
Father's Initials*
Mother's Initial*
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Family Information

Child's Information

Tuition & Payment

Enrollment Agreement

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