Hebrew School Registration

BH
We are currently accepting applications for the 2021-2022 school year.
Please fill out ALL fields of this form.
If you have any questions or concerns you'd like to discuss, feel free to contact.
Please note that one registration form per child is needed. In addition we need to have a Health form per child.
We look forward to a wonderful year of learning and growth.
STUDENT INFORMATION
Full Name*
First NameMiddle NameLast Name
Hebrew NameIf child has one
Date of Birth
MonthDayYear
School attending
Grade enteringSeptember 2019
PARENT INFORMATION

Home Address

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

Home Phone Number
Area CodePhone Number
Mother
Full Name
First NameLast Name
Hebrew NameIf mother has one
Occupation
Cell phone Number
Area CodePhone Number
E-mail*
Father
Full Name
First NameLast Name
Hebrew NameIf father has one
Occupation
Cell phone Number
Area CodePhone Number
E-mail*
Important Information
Are there any conversions in the family?*If yes, please describe:
Is anyone not Jewish in the family?*If yes, please specify who:
What Jewish experience are you looking for for your child?
EMERGENCY INFORMATION
Emergency Contact 1
Phone Number
Area CodePhone Number
Emergency Contact 2
Phone Number
Area CodePhone Number
Allergies and Medical conditions
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.
Medical Conditions
AUTHORIZATION
As the parent(s) or legal guardian of the above child, I/we authorize any adult acting on behalf of Chabad Jewish Center 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, we 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 Chabad Hebrew School activities, join in class trips and allow my child to be photographed while participating in Chabad Hebrew School and that these pictures may be used for marketing purposes.
Agree to Authorization*
I Agree
Initials*Verified as an Electronic Signature
PAYMENT OPTIONS
• Tuition for the coming year will be $600, + $50 (which includes books and supply fees.)
• A $50 non-refundable registration fee is required at the time of registration, this will be included in the complete tuition. The remaining $600 balance should be paid online or by check before the first Class.
• Scholarships are available upon request. If you need a scholarship, please send a copy of your 1040 tax return for 2019.
• The tuition balance can be paid online by credit card or by check, mailed to Chabad Jewish Center 35 Horace St Mansfield, MA 02048
Total
$0.00

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STUDENT INFORMATION

PARENT INFORMATION

Mother

Father

Important Information

EMERGENCY INFORMATION

Allergies and Medical conditions

AUTHORIZATION

PAYMENT OPTIONS