New Student Registration

Student Information
Full Name*

First Name Last Name
Hebrew Name*
Birth Date*

Month Day Year
Age*
*

Male Female
Does you child read basic Hebrew?*

None Somewhat Well
Does your child speak/understand Hebrew?*

None Somewhat Well
Does your child have previous Jewish Education*

Yes No
If yes, please describe:
What school does your child attend?*
Grade entering:*
Synagogue affiliated with:*
Is the natural mother of the child Jewish?*

Yes No
Were there any conversions or adoptions in your 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

First Name Last Name
Home Phone Number

Area Code Phone Number
Work Phone Number

Area Code Phone Number
Cell Phone Number

Area Code Phone Number
E-mail
Occupation

Address

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

Mother's Name

First Name Last Name
Home Phone Number

Area Code Phone Number
Work Phone Number

Area Code Phone Number
Cell Phone Number

Area Code Phone Number
E-mail
Occupation

Address (if different from above)

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

Emergency Contact Information

Please list two contacts to be used in case of emergencies (other than your home and business numbers).
Full Name*

First Name Last Name
Relationship to child*
Home Phone Number*

Area Code Phone Number
Work/Cell*

Area Code Phone Number

Address*

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

Full Name*

First Name Last Name
Relationship to child*
Home Phone Number*

Area Code Phone Number
Work/Cell*

Area Code Phone Number

Address*

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

Medical Information

Please send a copy of your insurance card for our files.
Child's physician or medical facility*
Physician's phone*

Area Code Phone Number

Physician's address*

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

Health Insurance*
Group #*
ID#*
Up to date with vaccinations?*

Yes No
Date of last tetanus shot:*

Month Day Year
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.
I hereby give permission for my child to participate in all school activities, join in class and school trips and beyond school properties. I hereby give permission for Chabad Hebrew School to photograph my child and to use the images in website, newsletter and flyers.
*

Accept Do Not Accept
Initial here:*
Chabad Hebrew School Tuition Agreement
The following is a tuition agreement for the Chabad Hebrew School. The agreement explains the tuition fees, payments plans and refund policies. Please read it through carefully. If paying by check or cash, full payment must be submitted to the school office before any child will be permitted to attend classes.

The tuition for the Chabad Hebrew School is $800.00 per year per child (this includes a registration & book fee). Register before September 5th for a 10% discount!

There is a 5% sibling Discount.

First year Hebrew school students are free not including a $180 book fee.
Refunds for children withdrawing from school before the end of the school year will be pro-rated up to February 1 provided that the school office is given 30 days written notice and does not include a $180 registration and book fee. Tuition refunds will not be granted to children withdrawing from school after February 1. There are no refunds or credits for days missed due to illness, holidays, or family vacations.
*

Accept Do Not Accept
Your FULL name here:*
Payment Options:
Required for all new students:

Book Fee - $180
Book Fee:

$180.00

Payment

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Student Information

Parent Information

Emergency Contact Information

Medical Information

Chabad Hebrew School Tuition Agreement

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