ENROLLMENT FORM Chabad Hebrew School 2018-2019 Family Name: 1. Child's First Name: Hebrew Name: Date of Birth: Grade (2018-19): 2. Child's First Name: Hebrew Name: Date of Birth: Grade (2018-19): 3. Child's First Name: Hebrew Name: Date of Birth: Grade (2018-19): 4. Child's First Name: Hebrew Name: Date of Birth: Grade (2018-19): Click here if all the details are the same as last year - and then no need to refill this form, Go straight to the payment Address City, State Zip Home Phone Mother (or Guardian name) Occupation Bus. Phone Bus. Address Cell Phone E-mail Father (or Guardian name) Occupation Bus. Phone Bus. Address Cell Phone E-mail S TUDENT I NFORMATION : Is the biological mother Jewish? Yes No Is the biological father Jewish? Yes No Were there any conversions or adoptions in the family? Yes No If Yes, who was the Rabbi? Additional comments: any educational concerns that will help us with your child Tuition and Fees $1100 + $36 book and supply fee +$100 (per family) Security $450 for Hebrew school enrichment class on Wednesdays - if there is enough children I would like to sponsor the Jewish education of another child for $1000. I would like to contribute $36 $72 $180 $360 other toward the Jewish education of another child. Total: Payment Options Please check one: I will send a check Please charge my credit card Credit Card Number Expiration Date Please call me to arrange a payment plan Please send me a scholarship application form *No child is turned away due to lack of funds **Registration will not be not accepted without full payment or without a completed scholarship form or payment plan form. I allow CHS to take pictures of my child/ren for our website and other PR purposes Volunteer I would like to volunteer at Chabad. My area of expertise Computers Graphic Design Handyman Dinner Committee Organization Other Emergency File Doctor’s Name Doctor's Phone Doctor’s Address Allergies Medical Conditions Other P LEASE LIST BELOW T WO EMERGENCY CONTACTS : Name Phone Relationship Name Phone Relationship PERMISSION FOR EMERGENCY MEDICAL TREATMENT: As the parent(s) or legal guardian of , I/we authorize any adult acting on behalf of Chabad of Briarcliff's 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. Initials of Parent or Legal Guardian Comments: This page uses 128 bit SSL encryption to keep your data secure.
