Registration - North County Chabad Center

Family Information
Father's Name*
First NameLast Name
Father's E-mail*

Home Address*

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

Father's Hebrew Name
Father's Occupation
Father's Work Address
Father's Phone Number*
Area CodePhone Number
Mother's Name*
First NameLast Name
Mother's E-mail*
Mother's Hebrew Name
Mother's Occupation
Mother's Work Address
Mother's Phone Number*
Area CodePhone Number
Synagogue Affiliation
Student Information
Child's Name*
First NameLast Name
Hebrew Name
Child's E-mail
Birth Date*
MonthDayYear
Age*
School*
Grade Entering*
Religious & Educational History
Previous Hebrew Education*
Were there any conversions and/or adoptions in the family*
NoYes
If yes, what relation to the family?
Where was the conversion done? Who was the Rabbi who performed the conversion?
Medical and Emergency Contact Information
Up to date with vaccinations?*
YesNo
Any special medical or other information, which we should be aware of including allergies?
Family Physician*
First NameLast Name
Family Physician Phone Number*
Area CodePhone Number
Medical Insurance Co
Policy Number
Person to be contacted in case of an emergency when parents cannot be reached:*
First NameLast Name
Emergency Contact Phone Number*
Area CodePhone Number
Relationship to Child*
Medical Release*
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.
Participation Waiver*
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.
Payment Information
Tuition*
Full Tuition - $700Scholarship Request
Total
$0.00

Payment

Credit Card

Credit Card Type
Credit Card Number	Security Code
Name on Card
Expiration Month	Expiration Year

Billing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Should be Empty:

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Family Information

Student Information

Religious & Educational History

Medical and Emergency Contact Information

Payment Information