Register Online | Chabad Hebrew School

We are currently accepting application forms for the 2011-2012 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. EARLY BIRD DISCOUNT UNTIL JULY 10th.

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

Name
Last
Hebrew Name
DOB
School
Grade Entering
Hebrew Reading Proficiency	None Somewhat Well
Previous Jewish Education	Yes No
Where?

Parent Information

Address
City/Zip
Phone
Email Address
Father's Name
Father's Occupation
Father's Cell
Mother's Name
Mother's Occupation
Mother born Jewish?	Converted by whom?
Mother's Cell

Emergency Information

Emergency Contact 1
Phone
Emergency Contact 2
Phone
Doctor's Name
Doctor's Phone Number

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:

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

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.

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