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CHS Online Registration Form!

CHS Online Registration Form!

Chabad Hebrew School
Online Registration Form

We are currently accepting application forms for the 2016-2017 school year. Please fill out ALL fields of this form.

If you have any questions or concerns you'd like to discuss with us, please contact us.

If you would prefer to fill out this paper and mail it into our office, a PDF can be found here.

Please note that one registration form per child is needed.

We look forward to a wonderful year of learning and growth.

Student Profile
First Name
Last Name
Hebrew Name
DOB
Gender Male Female
School
Grade Entering
Hebrew Reading Proficiency None Somewhat Well
Hebrew Speaking Proficiency None Somewhat Well
Previous Jewish Education/Hebrew School Yes No
If yes, please describe
Synagogue afiliated with
Natural mother of child Jewish? Yes No
Conversions / adoptions in family? Yes No
If yes, please describe
Any considerations, such as learning disorder or difficulty, the school should be aware of? (Confidential):


Parent Information
Father's Name
Father Home Phone
Father Work Phone
Father Cell Phone
Father Email
Mother's Name
Mother Home Phone
Mother Work Phone
Mother Cell Phone
Mother Email
Address
City
State
Zip
Spouse Address (if different):

Emergency Information
Emergency Contact 1
Relationship to child
Home Phone
Cell Phone
Emergency Contact 2
Relationship to child
Home Phone
Cell Phone
Child Physician or Medical Facility
Physician Phone
Physician Address
Health Insurance
Group #
ID #
Up to date with vaccinations? Yes No
Last tetanus shot date? mm/dd/yr


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.



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:

 

Pay Online

For your convenience, you can now pay for Hebrew School online.

This page uses a secure connection and your information will not be shared with anyone.

Annual tuition: $625 (registration and book fee included)

Early bird registration: $600 if registered by July 15

Amount: $
Installments
Card Number
Last Name
Address
City
State
Zip
Card Type
Exp. Date
CW#


 

I heard about the Chabad Hebrew School from:

We look forward to a wonderful year of learning and growth!

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