Registration Form

Family Information
Father's Name*

First Name Last Name
Father's Hebrew Name

Address*

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

Home Number

Area Code Phone Number
Cell Number

Area Code Phone Number
E-mail*
Occupation
Mother's Name*

First Name Last Name
Mother's Hebrew Name

Address If different

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

Home Number

Area Code Phone Number
Cell Number

Area Code Phone Number
E-mail*
Occupation
Parents Marital Status
Child/ren Lives with
Paternal Grandparents Name

Address

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

Maternal Grandparents Name

Address

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

Were there any conversions or adoptions in your family? If yes, please explain:
Are the natural parents of the child/ren Jewish

Both Father Mother
Child Information
Child #1*

First Name Last Name
Hebrew Name
Date and Time of Birth*

Month Day Year
at Hour Minutes
Grade entering in Sept 2022
Previous Hebrew Education
My Child

Does Not Read Hebrew Can recognize Hebrew Letters Reads Slowly
Child #2

First Name Last Name
Hebrew Name
Date and Time of Birth

Month Day Year
at Hour Minutes
Grade entering in Sept 2022
Previous Hebrew Education
My Child

Does Not Read Hebrew Can recognize Hebrew Letters Reads Slowly
Child #3

First Name Last Name
Hebrew Name
Date and Time of Birth

Month Day Year
at Hour Minutes
Grade entering in Sept 2022
Previous Hebrew Education
My Child

Does Not Read Hebrew Can recognize Hebrew Letters Reads Slowly
Emergency Contact Information

In case of emergency, when neither parent can be reached, please give names of two people who will take responsibility for your child.
Full Name

First Name Last Name
Relationship
Phone Number

Area Code Phone Number
Full Name

First Name Last Name
Relationship
Phone Number

Area Code Phone Number
Medical Information
Is there any medical, developmental or behavioral information regarding your child/ren, of which our school should be made aware?
Does your child have behavioral support in his/her regular school?

Yes No Part time
Please list any medication your child is taking on a regular basis
Does your child have any allergies towards food or medication?
Does your child have need for an epi-pen? If yes, please provide a current epi-pen and written permission to administer to Hebrew School at the beginning of the school year.

Yes No
Child's Doctor
Phone Number

Area Code Phone Number
Hospital affiliation
The information on this form may be shared confidentially with Chabad Hebrew School staff and emergency responders as needed. In the event of a medical emergency with my child, I understand every effort will be made to contact me. If emergency care is needed, I authorize qualified professionals to provide assessment, diagnosis and any necessary emergency treatment. I understand that Chabad Hebrew School assumes no financial liability for expenses incurred due to accident, injury and/or unforeseen circumstance.

Parent acknowledges that Chabad Hebrew School serves children who are able to function successfully in a group setting. If, in the judgment of the school's Director, the child is not able to function in a group setting, the parent may be asked to withdraw the child. In the event that the parent is request to withdraw the child, the Director will work with the parent to identify possible alternative programs suitable for the child.
Parent's Signature
Date

Month Day Year
at Hour Minutes
Parent acknowledges that s/he has read the School Handbook and the Covid-19 Guidelines (both links located on admissions page).
Parent's Signature
Date

Month Day Year
at Hour Minutes
Tuition Information
A minimum $100 deposit per child is required with this form to secure a spot for your child/ren.

Enrollment is considered to be for the entire scholastic year. There will be no refunds even if the child is absent due to illness, holidays, vacations and snow days, or should the parents decide to withdraw the child from the program.
Payment Options
Full Payment Charge me in full today

CHILD 1 FULL PAYMENT Hebrew School, Grades Pre-K - 7 (by September) Sunday Mornings 9:30am - 12:00pm Tuition: $600 CHILD 2 FULL PAYMENT Hebrew School, Grades Pre-K - 7 (by September) Sunday Mornings 9:30am - 12:00pm Tuition: $600 CHILD 3 FULL PAYMENT Hebrew School, Grades Pre-K - 7 (by September) Sunday Mornings 9:30am - 12:00pm Tuition: $600
Pay in three Installments Please write amount of 1st installment

$
Total

$0.00