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New Student Registration

Hebrew School Registration Form
2020-2021/5781
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, who?
Part VI: Medical Information
Health insurance*
Is there any medical or other information (allergies, etc.) regarding your child that our school should be aware of?*
Part VII: Payment Information
Please check your choice for method of payment:*
Members: $750 per year (paid in full, with discount $720)Members: $187.50 (4 payments)Members: $93.75 (8 payments)Non-Members: $1000 per year (paid in full, with discount $970)Non-Members: $250 (4 payments)Non-Members: $125 (8 payments)
There is a $25 registration fee per child
Family Discount: 10% off each additional child.
There will be a 3% processing fee when using your credit card
Choose one:*
Plan A: I am paying the entire amount now, which entitles me to a $30 discount off regular tuition.Plan B: Please automatically charge my credit card at the beginning at each month
Amount to charge my card today
$
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

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: Payment Information