Student Information:

Name:
Hebrew name:
Birth date:
Does your child read basic Hebrew?
If Yes: Good Fair Poor
What school does your child attend?
Grade entering:
Is the natural mother of the child Jewish?
Were there any conversions or adoptions in your family?
If yes please explain:  

Parent Information:

Fathers name:
Home Phone:
Work Phone:
Mobile Phone:
Email:
Occupation:
   
Mothers Name:
Home Phone:
Work Phone:
Mobile Phone:
Email:
Occupation:
   
Address:
City, State and Zip:

Emergency Information:

Emergency Contact:


Home Phone:
Work Phone:
Mobile Phone:
Doctor:
Address:
City, State and Zip:
Phone:
Allergies or other medical condition:

As the parent(s) or legal guardian of I/we authorize any adult acting on behalf of Chabad Hebrew School to hospitalize or secure treatment for my child, in case of emergency. I further agree to pay all charges for that care and/or treatment.

I hereby give permission for my child to attend all field trips and outings sponsored by Chabad Hebrew School.

Payment Info:

The Chabad Hebrew school tuition for the program is $715.00
(this includes books, supplies and light food and snacks, 35.00 end of year celebration).
Tuition fees can be made in full payment or in two installments in September and January.
~ No child will be turned away due to lack of funds! ~
 
Name on card:
Card type:
Card Number:
Card Exp:

Membership info:
It is expected that Hebrew school participants participate with
membership, if not possible due to financial reasons, please discuss with the Rabbi. Thanks for understanding!