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  
Mother's Name   Hebrew Name  
Work Address   Phone  
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