HEBREW SCHOOL REGISTRATIONChild's Name*First NameLast NameHebrew NameGender*BoyGirlBirth Date*1 - January2 - February3 - March4 - April5 - May6 - June7 - July8 - August9 - September10 - October11 - November12 - DecemberMonth12345678910111213141516171819202122232425262728293031Day20172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920YearAge*School*Previous Jewish EducationGrade entering*Kindergarten1st2nd3rd4th5th6th7th8th9thDoes your child read basic Hebrew?NoPoorFairWellDoes your child speak Hebrew?NoPoorFairWellAddress*Street AddressStreet Address Line 2CityState / ProvincePostal / Zip CodePlease SelectUnited StatesAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanThe BahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChilePeople's Republic of ChinaRepublic of ChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCook IslandsCosta RicaCote d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonThe GambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNagorno-KarabakhNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandTurkish Republic of Northern CyprusNorthern MarianaNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint BarthelemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSomalilandSouth AfricaSouth OssetiaSpainSri LankaSudanSurinameSvalbardSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTransnistria PridnestrovieTrinidad and TobagoTristan da CunhaTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamBritish Virgin IslandsUS Virgin IslandsWallis and FutunaWestern SaharaYemenZambiaZimbabweOtherCountryAdditional notable InformationFather's Name*First NameLast NameFather Cell*Area CodePhone NumberFather's Work PhoneArea CodePhone NumberFather's Email*Father's Occupation*Mother's Name*First NameLast NameMother Cell*Area CodePhone NumberMother's Work PhoneArea CodePhone NumberMother's Email*Mother's Occupation*Home Phone*Area CodePhone NumberMarital status of parents*SingleMarriedSeparatedDivorcedWidowedMedical FormDoctor's name*Doctor's phone*Doctor's address*Is your child covered by Medical Insurance?*YesNoInsurance Company*Policy NumberDoes your child have any allergies or other medical condition we should be aware of?*YesNoIf yes, please describe them and indicate special precautions or care neededPlease list two Emergency Contacts1. Name*Relationship*Home phone*Cell phone*2. NameRelationshipHome phoneCell phoneIn case of a medical emergency, I understand that every effort will be made to contact the parents, guardians or family physician. In the event of an emergency, where such a person cannot be reached, I hereby give permission to the physician/hospital selected by Chabad Hebrew School to hospitalize and secure proper treatment for my child. I further agree to pay for all charges for that care and/or treatment.I hereby give permission for my child to attend all filed trips and outings sponsored by Chabad Hebrew School.I hereby give permission for my child to be photographed or videoed as part of his/her and other children's enjoyment, and for possible use in advertising and promotions.Parent or Guardian Signature:*Date:*PaymentThe following document is a tuition agreement for the Chabad Hebrew School. The agreement explains the tuition fees, payment plans, and refund policies. Please read it through carefully and sign below. The signed tuition agreement along with full payment must be submitted before any child will be permitted to attend classes. The tuition for the Chabad Hebrew School is $600 per year per child (this includes the registration and book fee). There is a 10% discount off of the regular tuition for each additional child of the same family. You may choose from the following payment methods: Plan A: You may pay the entire amount in full entitling you to a $100.00 discount off of the regular tuition. Plan B: You may pay the annual tuition on a monthly basis by submitting 10 checks of $60.00 each, dated September through June. All checks must be submitted before the first day of Hebrew School. Plan C: You may use your Visa or Master Card to pay the tuition. Your credit card will be billed $60.00 monthly September through June. To do so, please include your credit card number and expiration date. Refunds for children withdrawing from school before the end of the school year will be granted provided that the school office is given 30 days written notice. Tuition refunds will not be granted to children withdrawing from school after April 1st.Payment Plan$500 Plan A- Entire Balance at once$450 Plan A- Entire Balance at once for a 2nd child$600 Plan B- Monthy payments of 10 checks$540 Plan B- Monthly payments of 10 checks for a 2nd child$600 Plan C- 10 Monthly charges by credit card$540 Plan C- 10 Monthly charges by credit card for a 2nd childPayment*Credit Card Other Credit CardVisaMasterCardAmerican ExpressDiscoverCredit Card TypeCredit Card NumberSecurity CodeName on Card1 - January2 - February3 - March4 - April5 - May6 - June7 - July8 - August9 - September10 - October11 - November12 - DecemberExpiration Month2017201820192020202120222023202420252026Expiration YearBilling AddressStreet AddressStreet Address Line 2CityState / ProvincePostal / Zip CodePlease SelectUnited StatesAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanThe BahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChilePeople's Republic of ChinaRepublic of ChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCook IslandsCosta RicaCote d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonThe GambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNagorno-KarabakhNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandTurkish Republic of Northern CyprusNorthern MarianaNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint BarthelemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSomalilandSouth AfricaSouth OssetiaSpainSri LankaSudanSurinameSvalbardSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTransnistria PridnestrovieTrinidad and TobagoTristan da CunhaTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamBritish Virgin IslandsUS Virgin IslandsWallis and FutunaWestern SaharaYemenZambiaZimbabweOtherCountryAdd to mailing listSubmitShould be Empty: This page uses TLS encryption to keep your data secure.