Hebrew School Registration Form

Address*

Phone Number*

Area Code Phone Number
E-mail*
Child 1 (name and Hebrew name)*
Birth Date*

Month Day Year
Child 2 (name and Hebrew name)
Birth Date

Month Day Year
Child 3 (name and Hebrew name)
Birth Date

Month Day Year
In case of injury of a child, every effort will be made to contact the parent or guardian.
In case of emergency, call:
Full Name*
First Name Last Name
Phone Number*

Area Code Phone Number
Full Name*
First Name Last Name
Phone Number*

Area Code Phone Number
Personal history:
Are the child/ren's parents living together?*

YesNo

Mother's or father's address if different

Phone Number

Area Code Phone Number
Is the Maternal grandmother Jewish?*

YesNo
Are there any conversions in the family?*

YesNo
If yes

MotherFatherGrandmotherGrandfatherEarlier conversion
Please email conversion certificate to [email protected].

Please note: As per Chabad policy and Israel Rabbinate policy, we only accept Orthodox conversion certificates.
Does your child have any allergies? If yes please specify*
Fees
$40 Per month
If more than one child is attending, please put in the correct amount in the area where you can fill in other total (e.g. 2 children would be $80 a month).
Payment options*

Full payment of $400 submitted with this form9 postdated checks of $40recurring automatic monthly payment of $40 (please also check off the recurring option below, if more than one child click on other and put in the correct amount)
$40$360
Yes, I'd like to make this a monthly recurring payment.

Payment

Credit Card Paypal Check

Postal / Zip Code

Country

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