Register

Please fill out this form as an initial registration for Chabad Hebrew School.
Student Information
Full Name*
First Name Last Name
Hebrew Name
Age*
Gender*

MaleFemale
Birth Date*

Month Day Year
Does your child have previous Jewish Education*

YesNo
If yes, please describe:
What school does your child attend?*
Grade entering:*
Synagogue affiliated with:*
Is the natural mother of the child Jewish?*

YesNo
Have you, your spouse, parent, grandparent, or child ever converted to Judaism?*

YesNo
Were there any adoptions in your family?*

YesNo
If yes to either of the above questions, please describe:
Does your child read basic Hebrew?*

NoneSomewhatWell
Does your child have any difficulty with general studies?
Parent Information
Parent's Name*
First Name Last Name
Phone Number*
Occupation*
E-mail*

Address*

Emergency Contact Information
Please list a contact to be used in case of emergencies (other than your home and business numbers).
Emergency Contact (other than parent)*
First Name Last Name
Relationship to a child*
Phone Number*

Address*

Additional person authorized to pickup your child (besides parents/guardians)
First Name Last Name
Relationship to Child
Phone Number

Address

Address*

Payment*

Credit Card Check

Postal / Zip Code

Country

Payment Options:

Payment in fullPayment in 5 installments
As the parent(s) or legal guardian of the above child, I/we authorize any adult acting on behalf of Chabad Hebrew School to hospitalize or secure treatment for my child, I further agree to pay all charges for that care and/or treatment. It is understood that if time and circumstances reasonably permit, Chabad Hebrew School personnel will try, but are not required, to communicate with me prior to such treatment. I hereby give permission for my child to participate in all school activities, join in class and school trip on and beyond school properties and allow my child to be photographed while participating in Chabad Hebrew School activities.*

Accept
I would like to receive news and updates by email
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Student Information