B”H

CHABAD HEBREW SCHOOL FORMS

Tuition is $800 per year. Meets Sundays 9:30am-11:30am

Registration Application 2018-2019

Please Print Clearly and Return to Office:

 

Part I: Student Information

Last Name

First Name

Hebrew Name

e-mail (child’s)

Address

City

Zip

Phone

Birthday

Age

School

Grade (Entering)

Part II: Parents’ Information

Father’s Name		Hebrew Name
Work Address		Phone						Occupation
Mother’s Name		Hebrew Name
Work Address		Phone						Occupation
e-mail (parent)		Synagogue Affiliation
Father cell #		Mother Cell #

Part III: Religious & Educational History

Previous Hebrew Education
Were there any conversions &/or adoptions in the family? (child, parent, grandparent, great grandparent both sides…)
If yes, what is the relation to the child?
Where were the conversion done? Who was the Rabbi who performed the conversion and which temple aviliation?

Part IV: Medical Information  (confidential)

Up to date with vaccinations?		Yes		No
Any special medical or other information, which we should be aware of including allergies?(Confidential)

Please Print Clearly and Return to Office:

Registration Application 2018-2019

 

___ I have included the $150 deposit towards the tuition payment.

 

___ I have included the payment in full.

 

___ I have included checks posted for the 1st of each month.

 

Please bill my credit card for $_____ on the 1st of Each month, September 2017-May 2018.

 

CC INFO

Type ________ Number ______________________________

 

EXP ________ CVC _________

For other options, please call 714-693-0770.

Chabad does not turn away any Jewish families due to lack of funds.

I hereby permit my child, _____________________________________to participate in all school activities, and to join in class and school trips on and beyond school properties and use any transportation selected by the Chabad Hebrew School.
Signature of parent________________________________Date:__________________

Emergency Contact Information
Person to be contacted in case of an emergency when parents cannot be reached:

Name				Telephone #		(      )       -
Relationship to child				City/Town
Family Physician				Telephone #		(      )       -
Medical Insurance Co.				Policy #

Medical Release Form

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________________________________Date______________