Chabad Hebrew School Registration

Enrollment Form

Please fill out the form below for the Chabad Hebrew School. 

Student Information 
(To register more than one child, simply fill out the student & emergency information a second time after submitting the completed form once.)

 Last Name        First Name  Hebrew/Jewish Name   
      
 Date of Birth      Age
     Male Female

Home Address                                 City                   State       Zip
   

Name of School                                                     Grade 2010/11
        

Does your child read basic Hebrew? Yes No
If yes: Well  Fair  Poor 

Does your child have any difficulties with his/her general studies? Yes No    
If yes, please explain:

Parent Information
 
Mother's Name                            Home Phone                       Work Phone
  
Cell Phone                                     Email
 

Father's Name                            Home Phone                       Work Phone
  
Cell Phone                                    Email
 

Family Information

Were there any conversions or adoptions in your family? No Yes        If yes, please explain:

 

Emergency Information

Emergency Contact (other than parent)
 
Relationship to child              Home Phone            Cell Phone 
      
Physician or medical facility                      Physician's phone    
Physician's Address                               Allergies (please list)
     
Medical Conditions (If any, please explain)

Permission for Emergency Medical Treatment: As the parent(s) or legal guardian(s) of the above child, I/we authorize any adult acting on behalf of Chabad Jewish Community Center 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 Jewish Community Center Hebrew School will try to communicate with me prior to such treatment. Accept  Do Not Accept      
 Initial here:  

Tuition Payment:

$575 + $25 Registration fee, includes registration, book fee and all supplies.
(No child will be turned away due to lack of funds).

Discounts :
5% discount for each additional child of the same family.

5% additional discount off your total tuition for each child of another family you successfully introduce to the Hebrew School. 

For a free info packet please email [email protected]