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We are currently accepting application forms for the 2014-2015 school year. Please fill out ALL fields of this form. If you have any questions or concerns you'd like to discuss with us, or if you would prefer to fill out this paper and mail it into our office, please contact us.

Please note that one registration form per child is needed.

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

Student Profile
 
Name
Last
Hebrew Name
DOB            
Gender Male           Female
School
Grade Entering
Hebrew Reading Proficiency None    Somewhat    Well
Hebrew Speaking Proficiency None    Somewhat    Well
Previous Jewish Education 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:

 

Payment Information

Full tuition $500
Payment Plan $100 Deposit (and 100 for the next 4 months)
I will pay by check 

 

Amount* $
Card Type*
Card Number*
Expiration Date*
CVV Security Code What's This?

 

I heard about the Chabad Hebrew School from:

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

 

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Wishing you and your children a happy, healthy, and safe summer!