Enroll

Registration
Child's Name*

First Name Last Name
Hebrew Name*
Birth Date*

Month Day Year
Exact time of day child was born? (To determine Childs Hebrew Birthday)*
Sex *

MaleFemaleN/A
School
Previous Jewish Education*

if yes, please specify
How did your hear about CHS?
Grade Entering
Does your child read basic Hebrew?
Previous Hebrew School Education? if yes please specify*

if yes, please specify
Summer camp your child attends
Does your child have any Learning Difficulties that we should know about?
Does your child have any allergies or any other medical condition we should be aware of?
Does your child take any medicine on a regular basis?
Is your child up to date on immunizations? please include a copy of your childs immunization records. *
Doctor name/office*
Doctors Phone Number*

Area Code Phone Number
Who else is allowed to pick up my child/ren?

First Name Last Name
Phone Number

Area Code Phone Number
Additional Information

Please write anything we should know about your child.
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 trips on and beyond school properties and allow my child to be photographed while participating in Chabad Hebrew School activities and that these pictures may be used for marketing purposes
I accept*

Yes
Parent Information
Parents Marital Status

MarriedSeparatedDivorcedSingle
Father's Name*

First Name Last Name
Fathers Hebrew Name
Name of Employment

Place of Employment

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

Father's Cell*

Area Code Phone Number
Fathers E-mail
Father Born Jewish?*

YesNo
Conversion performed by?
Mother's Name*

First Name Last Name
Mothers Hebrew Name
Name of Employment

Place of Employment

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

Mother's Cell*

Area Code Phone Number
Mothers E-mail
Mother born Jewish?*

YesNo
Conversion performed by?
Are there any adoptions in the family? Please specify*
Are there any conversions in the family? Please specify.*
Emergency Contact #1*

First Name Last Name
Phone Number*

Area Code Phone Number
Emergency Contact #2

First Name Last Name
Phone Number

Area Code Phone Number
How would you like to receive updates with regards to Hebrew School?
I would like more information

Mommy and Me (kids 0-4)Kids in the Kitchen (ages 4-13Camp Gan Israel (ages 3-13Bat Mitzvah Club (girls ages 11-13Bar/Bat Mitzvah LessonsCTeen (humanitarian/social program)Adult EducationSynagogue InformationCTeen Jr (middle school)
Payment
Rates per Child*

$700$75 (if registering after August 21th)
I would like to donate to the Chabad Hebrew School Scholarship Fund

$54$100$180
Total

$0.00

I would like to pay today:Full amount$100.00 minimum$

Payment*

Credit Card Other

Postal / Zip Code

Country

I would like to receive news and updates by email
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Registration

Parent Information

Payment