Hebrew School Registration - Chabad of Lakeview

Child's full name:

Child's Hebrew name:

Child's Birthday (mm/dd/yy):*

Grade Entering in Fall '18:*

School Attending in Fall '18*

* We ask the following questions in order to better relate to and understand each child!

Please describe any previous Jewish education (if any):

Hebrew reading proficiency:*

NoneSomeWell

Marital status of parents:*

Are both parents Jewish?*

YesNo

If answered "no" to the above question, please explain:

Any conversions or adoptions in the family?*

YesNo

If answered "yes" to the above question, please explain:

Mother's full name:

Mother's Hebrew name:

Mother's cell phone:

Mother's email:

Father's full name:

Father's Hebrew name:

Father's cell phone:

Father's email:

Emergency contact full name:*

Emergency contact relationship:

Emergency contact phone:*

Please specify any allergies and/or medications taking (indicate if none):*

Please indicate any medical or special circumstances, diagnosed learning disabilities, or any other info we should know to best care for your child (indicate if none):*

Please read and accept the following release statement:

As the parent(s) or legal guardian of the above child, I/we authorize any adult acting on behalf of Chabad of Lakeview's Hebrew School program to treat, hospitalize or secure treatment for my child in case of emergency; I further agree to pay all charges for that care and/or treatment. It is understood that if time and circumstances reasonably permit, 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 and I understand that my child may be photographed while participating in school activities and that these pictures may be used for marketing purposes.

By providing my electronic signature (enter full name) below, I accept these terms and conditions.

Signature:*

Today's date:*

Tuition for the 2018-19 school year is $900 . (For the post bar/bat mitzvah year program, a $100 book and special activity fee will be added.)

If you select the payment plan, you will be charged equal monthly installments now through May 2019 (the first payment will process now, subsequent payments at the end of each month). Mid-year registrations will be prorated.

Select one:*

Pay in full nowPayment plan (equal monthly installments now thru May 15th, 2019)

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

Chabad Hebrew School Registration - 2018/19 School Year