New Student Registration

Hebrew School Registration Form
2022-2023/5783
If your child is a returning student please fill out our quick and easy registration form here .
Part I: Student’s Information
Child's Full Name*
First NameLast Name
*
MaleFemale
(Child’s) E-mail

Address*

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

Phone Number*
Area CodePhone Number
Day School*
Grade*
Age*
Birthday*
MonthDayYear
Parents’ Information
Mother's Full Name*
First NameLast Name
Father's Full Name*
First NameLast Name
Father's E-mail*
Mother's E-mail*
Home Phone Number
Area CodePhone Number
Father's Cell Phone Number*
Area CodePhone Number
Father's Work Phone Number
Area CodePhone Number
Mother's Cell Phone Number*
Area CodePhone Number
Mother's Work Phone Number
Area CodePhone Number
Part III: Family
Brother
Birth Date
MonthDayYear
Brother
Birth Date
MonthDayYear
Brother
Birth Date
MonthDayYear
Sister
Birth Date
MonthDayYear
Sister
Birth Date
MonthDayYear
Sister
Birth Date
MonthDayYear
Part V: Hebrew Education
Father's Hebrew Name*
Mother's Hebrew Name*
Child's Hebrew Name*
Does your child have any learning difficulties with general studies?*
YesNo
If yes, please describe
Is the natural mother of the child Jewish?*
YesNo
Where there any conversions or adoptions in the family?*
YesNo
If yes, please explain and note which side of the family
Part VI: Medical Information
Health insurance*
CONFIDENTIAL: Does your child have any allergies or other medical condition we should be aware of? If yes, please describe them and indicate special precautions or care needed.*
Part VII: Emergency Information
Emergency Contact 1*
First NameLast Name
Contact 1 Phone Number*
Area CodePhone Number
Emergency Contact 2
First NameLast Name
Contact 2 Phone Number
Area CodePhone Number
As the parent(s) or legal guardian of the above child, I/we authorize any adult acting on behalf of the 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, the 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 the Chabad Hebrew School activities and that these pictures may be used for marketing purposes.
I Accept*
First NameLast Name
Part VIII: Payment Information
DISCOUNTED PRICING FOR 2022/2023
Information and Payment
Members:  $850/ year
Non-Members:  $1100/ year
Family Discount:  10% off each additional child
$50 Early Bird Discount if you sign up by May 25th, 2022
Registration fee $75 per child
There will be a 3% processing fee when using your credit card
Registration*
$75
Member Pricing
1 Child, full upfront: $820 (with discount)1 Child, 4 payments: $212.502 Children, full upfront: $1585 (with discount)2 Children, 4 payments: $403.75
Non-Member Pricing
1 Child, full upfront: $1070 (with discount)1 Child, 4 payments: $2752 Children, full upfront: $2060 (with discount)2 Children, 4 payments: $522.50
Total
$0.00
Yes, I'd like to donate the cost of processing this transaction by adding 3%

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

Questions/Comments:
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. If for any reason you decide to cancel during the year, you will be refunded/ not charged from the beginning of the next month. There are no refunds after May 1st. I understand that by recieving the early bird discount my first payment is non-refundable.
OFFICE USE ONLY
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Part I: Student’s Information

Parents’ Information

Part III: Family

Part V: Hebrew Education

Part VI: Medical Information

Part VII: Emergency Information

Part VIII: Payment Information