HEBREW SCHOOL REGISTRATION Please fill out ALL fields of this form. If you have any questions or concerns you'd like to discuss with us, please contact us. At the bottom of the registration form please be sure to fill out the information needed for registration. There is a $100 registration fee. Tuition can either be billed to you or charged now. Classes for the 2021-2022 school year will be held on Sunday mornings from 9:45am-11:45 am Please note that one registration form per child is needed. We look forward to a wonderful year of learning and growth. STUDENT INFORMATION First Name Last Name Hebrew Name D.O.B. Month Jan. Feb. Mar. Apr. May Jun. Jul. Aug. Sept. Oct. Nov. Dec. Date 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 School Grade Entering Grade Entering Preschoool Kindergarten First Second Third Fourth Fifth Sixth Seventh Hebrew Reading Proficiency None Somewhat Well Previous Jewish Education Yes No If yes - where? Father's Hebrew Name Mother's Hebrew Name PARENT INFORMATION Father's Name Father's Cell Mother's Name Mother's Cell Address City, State, Zip City State Zip Home Phone Email Were there any conversions or adoptions in the family? Yes No If yes, please explain: EMERGENCY INFORMATION Emergency Contact 1 Phone Emergency Contact 2 Phone 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. 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 Name: Initials: PAYMENT OPTIONS • Tuition for the coming year will be $750 in addition to the $100 registration fee. • $100 will be charged now (unless otherwise noted by you) and the remaining tuition balance can be paid by check, mailed to Chabad Hebrew School • 521 A1A N • Ponte Vedra Beach, Fl 32082 Name on card Card Type Select American Express Visa Mastercard Charge Amnt. Card Number Exp. Date Month 01 02 03 04 05 06 07 08 09 10 11 12 Year 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030 CVV Code 3 digits on back of card This page uses 128 bit SSL encryption to keep your data secure.