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Registration 2021

Hebrew School Registration 2021/2022
CHILD'S INFO:
Full Name*
First NameLast Name
Hebrew Name
Gender*
MaleFemale
Birth Date*
MonthDayYear
Time of Birth
HourMinutes
School Attending*2020/2021
Grade*2020/2021
Past Hebrew Lessons*
No previous HSPrivate Tutor
Please choose a program:*
Grades K-2Grades 3-6Grade 7
Register another child?
YesNo
Child 2: Full Name
First NameLast Name
Hebrew Name
Birth Date
MonthDayYear
Time of birth
HourMinutes
School Attending2020/2021
Grade2020/2021
Past Hebrew Lessons
No previous HSPrivate Tutor
Please choose a program:
Grades K-2Grades 3-6Grade 7
Parents
Parent Marital Status*
Child lives with*
Is the biological parent of the child Jewish?*
YesNo
Have their been any conversions or adoptions in the family?*
YesNo
Please specify Rabbi & Congregation
PARENT 1:
Parent 1 Title*
Parent 1 Full Name*
First NameLast Name
E-mail*
Cell Phone*
Area CodePhone Number
Work Phone*
Area CodePhone Number
Occupation*
PARENT 2:
Parent 2 Title
Parent 2 Full Name
First NameLast Name
E-mail
Cell Phone
Area CodePhone Number
Work Phone
Area CodePhone Number
Occupation
HOME:

Home Address*

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

Home Phone
Area CodePhone Number
Medical/Emergency Information
EMERGENCY CONTACT:
Full Name*
First NameLast Name
Phone Number*
Area CodePhone Number
Relationship*
MEDICAL & OTHER NEEDS:
Is your child taking permanent medications?*
YesNo
Any known allergies (incl. reactions to medications)?*
YesNo
Any present medical conditions?*
YesNo
Any learning disabilities?*
YesNo
If you answered yes to any of the questions above, please provide details here:
PHYSICIAN:
Family Physician*
Phone Number*
Area CodePhone Number

Address*

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

General Information
AUTHORIZATION FOR ANOTHER PERSON TO PICK UP MY CHILD:
Name of Authorized Person
First NameLast Name
Cell Phone of Authorized Person
Area CodePhone Number
Relationship of Authorized Person
TRIPS:
I give permission for my child/ren to participate on class trips throughout the school year:
Trips Permission*
YesNo
Tuition & Billing
K-2nd Grade
          Member: $900
          Non member: $1,150
3rd - 6th Grade
         Member: $1000
         Non member: $1,250
CTeen Jr. - 7th Grade (Meets Sunday morning PLUS two Sunday evenings each month.)
         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
Digital Signature of Parent or Legal Guardian*
Date*
MonthDayYear
PAYMENT OPTIONS:
Membership Status*Choose One
Chabad Mid Suffolk MemberNon Member
Payment Plan*Choose One
PLAN A: Pay the entire amount in full at time of registrationPLAN B: Pay $154 Fee today and the balance monthly (10) on the credit card
Total
$0.00

Payment

Credit Card Check

Postal / Zip Code

Country

Disclaimer
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.
Digital Signature of Parent or Legal Guardian*
Date*
MonthDayYear
Should be Empty:

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