Hebrew School Registration Form Part I: Student Information Last Name First Name Hebrew Name Email (child's) Address City State Zip Phone Birthday Age School Grade (Entering) Part II: Parents' Information Father's Name Hebrew Name Work Address Phone Occupation Mother's Name Hebrew Name Work Address Phone Occupation Email (parent) Synagogue Affiliation Father Cell Mother Cell Part III: Religious & Educational History Previous Hebrew Education Were there any conversions &/or adoptions in the family Yes No If yes, please explain Part IV: Program Hebrew School Private Tutoring I hereby permit my child to participate in all school activities, and to join in class and school trips on and beyond school properties and use any transportation selected by the Chabad Hebrew School. Part V: Tuition and Fees Tuition: $500 Registration Fee: $50 Scholarships available! Part VI: Emergency Contact Information Person to be contacted in case of an emergency when parents cannot be reached: Name Phone Relationship to Child City/Town Family Physician Phone Medical Insurance Co Policy Number Part VII: Medical Release Form In the event of an emergency, Chabad Hebrew School has my permission to arrange for any necessary first-aid or care by a licensed physician/first-aid worker at my expense. Chabad has my permission to use my child’s photo in its publicity materials. I have completed the Enrollment Form and have enclosed my registration fee and payment. I agree to pay any balance according to the Terms of Agreement outlined above. medical measures they deem necessary, at my expense, for my child in the event of a medical emergency. Parent's Signature Date This page uses 128 bit SSL encryption to keep your data secure.
