Chabad Hebrew School - Registration Form 2019-2020

Part I: Student Information

Last Name: First Name:
Hebrew Name: Birthday:
Address: Phone:
School: Current Grade (2017-18):

Part II: Parents’ Information

Mother’s Name: Hebrew Name:
Work Address: Occupation:
Cell Phone: Email:
Father’s Name: Hebrew Name:
Work Address: Occupation:
Cell Phone: Email:

Part III: Religious & Educational History

Does your child read basic Hebrew? Yes No Somewhat
Does your child have any learning difficulties with general studies? Yes No Somewhat
If Yes, please describe.
Were there any conversions and/or adoptions in the family? Yes No
If Yes, please explain.

Part IV: Medical Release Form

If parents not available contact:
Name: Cell phone:
Relation to child: City:
Medical Information: Family Physician:
Medical Insurance Co.    
Is there any allergies, medicines or other medical information which we should be aware of?(Confidential)

Medical Release Form

I hereby permit my child(ren) to participate in all school activities, and to join in all class and school trips, on or beyond school properties, and on any transportation selected by the Jewish Discovery Center.

I hereby give consent to the administration of the Chabad Hebrew School to take whatever medical measures they deem necessary, at my expense, for my child in the event of a medical emergency.

Signature of parent(Electronic Signature):

Part V: Payment


Tuition for the 2019-20 School year is as follows: 
Registration Fee: $50 per family
$700 per child
Security Fee: $75 per child – $150 family cap

If you refer a new family BOTH you and the new family will get a $50 Tuition Discount.

* No Membership Dues required.
 *There are no other registration, trip or snack fees. 

My total yearly payments will be:

Paying full tuition payment of with registration.

Paying which is 20% of tuition as a deposit, and will make eight automatic payments of on the first of each month, starting in September.

Other method of payment as arranged. Please specify:

Payment Method

Payment type
Card Number
Expiration Date / Security Code