Student Information
Last Name
First Name
Hebrew Name
DOB Year 
Grade Entering
Hebrew Reading Proficiency None Somewhat Well
Previous Jewish Education Yes No
Any consideration, such as learning disorder or difficulty the school should be aware of (confidential)
Parent Information
Father's Name
Father's Occupation
Father's Cell
Father's Email
Mother's Name
Mother's Occupation
Mother born Jewish?  Converted by whom?
Mother's Cell
Mother's Email
Emergency Information
Emergency Contact 1
Emergency Contact 2
Doctor's Name
Doctor's Phone Number
Medical Insurance Company
Policy Number

CONFIDENTIAL: Does your child have any allergies or other medical condition we should be aware of? If yes, please describe them and indicate special precautions or care needed.

Hebrew School Tuition plus supply fee: $900.00  (no one will be turned away due to a lack of funds, Scholarships available) 
Method of payment:
Credit Card / Master Card /Visa/ Amex
Check/ Zelle  (Zelle info [email protected])
Credit Card Information
Credit Card Number Billing Address
City State, Zip
Charge Amount Exp Date


As the he 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

Name: Initials: Date:

We look forward to a wonderful year of learning and growth!