2019-2020 Chabad Hebrew School Registration

    

Contact Information

Hebrew Name
Hebrew Mother
Hebrew Father
Country*
Email*
Confirm Email*
Cell Phone #*

First Child

Child Name*
Child Hebrew Name
Child Date of Birth*
Child School*
Child Grade*
If yes, where?
Does your child require any special needs? (Allergies, medication, food, etc.)

Second Child

Child Name
Child Hebrew Name
Child Date of Birth
Child School
Child Grade
If yes, where?
Does your child require any special needs? (Allergies, medication, food, etc.)

Third Child

Child Name
Child Hebrew Name
Child Date of Birth
Child School
Child Grade
If yes, where?
Does your child require any special needs? (Allergies, medication, food, etc.)

Emergency Contact Information

Emergency Contact Name 1*
Emergency Contact Relationship 1*
Emergency Contact Phone 1*
Emergency Contact Name 2
Emergency Contact Relationship 2
Emergency Contact Phone 2
Pediatrician Name*
Pediatrician Address
Pediatrician Phone
Insurance Company
Policy #

Tuition

Quantity
Price
Total
1st child First Taste (3-5 yrs)

(Non-Member)

X
$
350.00=
$
0

2nd child First Taste (3-5 yrs)

(Non-Member)

X
$
330.00=
$
0

3rd child First Taste (3-5 yrs)

(Non-Member)

X
$
310.00=
$
0

1st child Hebrew School

(Member)

X
$
750.00=
$
0

2 or more children Hebrew School Tuition

(Member)

X
$
718.00=
$
0

1st Child Hebrew School tuition

(Non-member)

X
$
1,050.00=
$
0

2 or more children Hebrew School

(non-member)

X
$
1,002.00=
$
0

Installment Payments

Request to make payment in monthly or quarterly installments.

X
$
200.00=
$
0

1st Child First Taste (3-5 yrs)

(Member)

X
$
300.00=
$
0

2nd Child First Taste (3-5 yrs)

(Member)

X
$
280.00=
$
0

3rd Child First Taste (3-5 yrs)

(Non-Member)

X
$
260.00=
$
0

Final Total:
$
0

Payment Information

Amount*
$
Name on Card*
Card Number*

Security

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