Hebrew School Registration Form

1. Child/ren’s Information
Child 1*
First Name Middle Name Last Name
Hebrew name
Birth Date*

Month Day Year
Gender*

MaleFemale
Grade entering this coming school year
Does the student have any difficulties in their general studies

NoYes
If yes, please explain
Is the natural born mother of the child/ren Jewish?

YesNo
Were there any conversions or adoptions in the family?

YesNo
If yes, please explain
If registering only 1 child skip to the contact information section, otherwise continue with child 2
Child 2
First Name Middle Name Last Name
Hebrew name
Birth Date

Month Day Year
Gender

MaleFemale
Grade entering this coming school year
Does the student have any difficulties in their general studies

NoYes
If yes, please explain
Child 3
First Name Middle Name Last Name
Birth Date

Month Day Year
Gender

MaleFemale
Grade entering this coming school year
Does the student have any difficulties in their general studies

NoYes
If yes, please explain
2. Contact information
Home Phone Number*

Area Code Phone Number

Home Address*

Mother's info
First Name Last Name
Work Phone

Area Code Phone Number
E-mail Primary email
Cell Phone

Area Code Phone Number
Father's info
First Name Last Name
Work Phone

Area Code Phone Number
E-mail
Cell Phone

Area Code Phone Number
How did you hear about us?
3. Emergency Information
Emergency Contact*
First Name Last Name
Phone Number*

Area Code Phone Number
Relationship*
4. Payment Information
Cost per student - $500

This includes tuition, registration and book fee.
I'd like to request a scholarship due to financial hardship
Number of children being registered: for Hebrew School*
Number of children being registered: for Hebrew Reading lessons*
Payment options

1 payment for the full amountDivide it into 10 monthly payments
I would to like help ensure that no child is turned away due to financial hardship by contributing to the scholarship fund in the amount of:

$50 - 1 tuition payment$500 - 1 year of Hebrew School
Total

$0.00

Payment method

Credit Card Cash/Check

Agreement*

I am signing up my child for Chabad Hebrew School. I give my child permission to attend all trips and receive medical care in the case of emergency, G-d forbid. I give Chabad Hebrew School permission to photograph and video my child/ren and use the photos/videos for whatever they see fit.
General comments
Should be Empty:

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Educate Your Child... Educate a Generation

1. Child/ren’s Information