New Student Registration Hebrew School - ChabadNorthHollywood.org

Tuesday Afternoons, 3:45- 6:00 PM
Tuition $950 + $50 registration fee

Child Name:*

First Name Last Name

Hebrew Name:*

DOB:*

Month Day Year

School Attending:*

Grade Entering:*

Hebrew Reading Proficiency:*

Previous Jewish Education*

YesNo

Is the Biological Mother Jewish?*

YesNo

Have there been any conversions or adoptions in the family?*

YesNo

Father's Name:*

First Name Last Name

Father's E-mail*

Mother's Name:*

First Name Last Name

Mother's E-mail*

Phone Number*

Address*

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

Emergency Contact Name 1:*

First Name Last Name

Emergency Contact 1 Phone Number:*

Emergency Contact Name 2:*

First Name Last Name

Emergency Contact 2 Phone Number:*

AS THE PARENT(S) OR LEGAL GUARDIAN OF THE ABOVE CHILD, I/WE AUTHORIZE ANY ADULT ACTING ON BEHALF OF CHABAD HEBREW SCHOOL TO HOSPITALIZE OR SECURE TREATMENT FOR MY CHILD, I FURTHER AGREE TO PAY ALL CHARGES FOR THAT CARE AND/OR TREATMENT. IT IS UNDERSTOOD THAT IF TIME AND CIRCUMSTANCES REASONABLY PERMIT, CHABAD HEBREW SCHOOL PERSONNEL WILL TRY, BUT ARE NOT REQUIRED, TO COMMUNICATE WITH ME PRIOR TO SUCH TREATMENT. I HEREBY GIVE PERMISSION FOR MY CHILD TO PARTICIPATE IN ALL SCHOOL ACTIVITIES, JOIN IN CLASS AND SCHOOL TRIPS ON AND BEYOND SCHOOL PROPERTIES AND ALLOW MY CHILD TO BE PHOTOGRAPHED WHILE PARTICIPATING IN CHABAD HEBREW SCHOOL ACTIVITIES AND THAT THESE PICTURES MAY BE USED FOR MARKETING PURPOSES.*

I accept

Full Name*

First Name Last Name

Initials*

Registration Fee

$50

Total

$50.00

Payment*

Credit Card

We accept Visa, MasterCard, American Express, Discover
Credit Card Number	Security Code
Name on Card
Expiration Month	Expiration Year

Please charge my balance:*

In full to the card above.Please charge the card above seven times, September through March.I will submit 7 checks, dated September through March. All checks must be submitted before the first day of Hebrew School.

Please choose from one of the following payment methods:

PLAN A: You may pay the entire amount in full. You may use your Visa, Amex or Master Card to pay the tuition. To do so, please include your credit card number and information at the bottom of this page.PLAN B: You may pay the annual tuition on a monthly basis by submitting 7 checks, dated September through March. All checks must be submitted before the first day of Hebrew School.PLAN C: You may use your Visa, AMEX or Master Card to pay the tuition.Your credit card will be billed seven times, Septmeber through March. To do so please include your credit card number and information at the bottom of this page.

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