Registration Form

Family Information
Father's Name*
First NameLast Name
Father's Hebrew Name

Address*

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

Home Number
Area CodePhone Number
Cell Number
Area CodePhone Number
E-mail*
Occupation
Mother's Name*
First NameLast Name
Mother's Hebrew Name

AddressIf different

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

Home Number
Area CodePhone Number
Cell Number
Area CodePhone 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
BothFatherMother
Child Information
Child #1*
First NameLast Name
Hebrew Name
Date and Time of Birth*
MonthDayYear
at HourMinutes
Grade entering in Sept 2022
Previous Hebrew Education
My Child
Does Not Read HebrewCan recognize Hebrew LettersReads Slowly
Child #2
First NameLast Name
Hebrew Name
Date and Time of Birth
MonthDayYear
at HourMinutes
Grade entering in Sept 2022
Previous Hebrew Education
My Child
Does Not Read HebrewCan recognize Hebrew LettersReads Slowly
Child #3
First NameLast Name
Hebrew Name
Date and Time of Birth
MonthDayYear
at HourMinutes
Grade entering in Sept 2022
Previous Hebrew Education
My Child
Does Not Read HebrewCan recognize Hebrew LettersReads 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 NameLast Name
Relationship
Phone Number
Area CodePhone Number
Full Name
First NameLast Name
Relationship
Phone Number
Area CodePhone 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?
YesNoPart 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.
YesNo
Child's Doctor
Phone Number
Area CodePhone 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
MonthDayYear
at HourMinutes
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
MonthDayYear
at HourMinutes
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 PaymentCharge me in full today
CHILD 1 FULL PAYMENT Hebrew School, Grades Pre-K - 7 (by September) Sunday Mornings 9:30am - 12:00pm Tuition: $600CHILD 2 FULL PAYMENT Hebrew School, Grades Pre-K - 7 (by September) Sunday Mornings 9:30am - 12:00pm Tuition: $600CHILD 3 FULL PAYMENT Hebrew School, Grades Pre-K - 7 (by September) Sunday Mornings 9:30am - 12:00pm Tuition: $600
Pay in three InstallmentsPlease write amount of 1st installment
$
Total
$600.00