CHILD'S INFO:

PARENT 1:

PARENT 2:

HOME:

EMERGENCY CONTACT:

MEDICAL & OTHER NEEDS:

PHYSICIAN:

AUTHORIZATION FOR ANOTHER PERSON TO PICK UP MY CHILD:

TRIPS:

I give permission for my child/ren to participate on class trips throughout the school year:

K-2nd Grade   
          Member: $900
          Non member: $1,150

3rd - 6th Grade  
         Member: $100
         Non member: $1,250

CTeen Jr. - 7th Grade
         Member: $1,200
         Non member: $1,650

PROGRAM & TUITION AGREEMENTS:

I hereby confirm my child’s enrollment in Chabad of Mid-Suffolk Hebrew School.

I represent that I am the custodial parent or legal guardian of the child that I am enrolling and that the information I have provided is true and correct. 

I fully understand that this enrollment, as part of my commitment to a long-term Jewish education at Hebrew School, is accepted only on the basis of the full year program, and agree to pay the full annual fees accordingly. I understand that no refunds or adjustments will be made for absences including, but not limited to, illness or vacation.

I agree to the following Mandatory Fees:
$54 Student Activity Fee per family
$154 Security Fee per family 

PAYMENT OPTIONS:

Accident: As the parent(s) or legal guardian of the above child/ren, 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 of Mid-Suffolk Hebrew School personnel will try, but are not required, to communicate with me prior to such treatment.

Trips and Outings: I hereby give permission for my child to attend and participate in all trips and outings organized as part of the program by Chabad of Mid-Suffolk Hebrew School.

Privacy: I hereby give permission for my child’s photographs/videos to be used in newsletters, local newspapers, Chabad of Mid-Suffolk Hebrew School website or for promotion of our program.