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Hebrew School Registration

HEBREW SCHOOL REGISTRATION
Child's Name*
First NameLast Name
Hebrew Name
Gender*
BoyGirl
Birth Date*
MonthDayYear
Age*
School*
Previous Jewish Education
Grade entering*
Does your child read basic Hebrew?
NoPoorFairWell
Does your child speak Hebrew?
NoPoorFairWell

Address*

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Additional notable Information
Father's Name*
First NameLast Name
Father Cell*
Area CodePhone Number
Father's Work Phone
Area CodePhone Number
Father's Email*
Father's Occupation*
Mother's Name*
First NameLast Name
Mother Cell*
Area CodePhone Number
Mother's Work Phone
Area CodePhone Number
Mother's Email*
Mother's Occupation*
Home Phone*
Area CodePhone Number
Marital status of parents*
Medical Form
Doctor's name*
Doctor's phone*
Doctor's address*
Is your child covered by Medical Insurance?*
YesNo
Insurance Company*
Policy Number
Does your child have any allergies or other medical condition we should be aware of?*
YesNo
If yes, please describe them and indicate special precautions or care needed
Please list two Emergency Contacts
1. Name*
Relationship*
Home phone*
Cell phone*
2. Name
Relationship
Home phone
Cell phone
In 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:*
Payment
The 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 child

Payment*

Credit Card Other

Postal / Zip Code

Country

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