Printed from ChabadBriarcliff.com

Hebrew School Registration Form

ENROLLMENT FORM
Chabad Hebrew School 2018-2019
Child 1:*
First NameLast Name
Child's hebrew name:*
First NameLast Name
Date of birth:*
MonthDayYear
Grade (2018-19):*
Child 1 Registration:*
$1000 + $36 book and supply fee +$75 Security$350 for Hebrew school enrichment class on WednesdaysFree for first year K class
K Class registrations- I would like to make a contribution of:
$180$360
Does your child require a Behavior Intervention Plan? Or behavior / management strategies to promote positive behavior?
If so, please describe.
Child 2:
First NameLast Name
Child's Hebrew name:
First NameLast Name
Date of birth:
MonthDayYear
Grade (2018-19):
Child 2 Registration:
$1000 + $36 book and supply fee +$75 Security$350 for Hebrew school enrichment class on WednesdaysFree for first year K class
K Class registrations- I would like to make a contribution of:
$180$360
Does your child require a Behavior Intervention Plan? Or behavior / management strategies to promote positive behavior?
If so, please describe.
Child 3:
First NameLast Name
Child's Hebrew name:
First NameLast Name
Date of birth:
MonthDayYear
Grade (2018-19):
Child 3 Registration:
$1000 + $36 book and supply fee +$75 Security$350 for Hebrew school enrichment class on WednesdaysFree for first year K class
K Class registrations- I would like to make a contribution of:
$180$360
Does your child require a Behavior Intervention Plan? Or behavior / management strategies to promote positive behavior?
If so, please describe.
Child 4:
First NameLast Name
Child's Hebrew name:
First NameLast Name
Date of birth:
MonthDayYear
Grade (2018-19):
Child 4 Registration:
$1000 + $36 book and supply fee +$75 Security$350 for Hebrew school enrichment class on WednesdaysFree for first year K class
Does your child require a Behavior Intervention Plan? Or behavior / management strategies to promote positive behavior?
If so, please describe.
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

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

Home phone:
Area CodePhone Number
Mother's (or guardian's) name:
First NameLast Name
Occupation:
Business phone:
Area CodePhone Number

Business address:

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

Cell phone:
Area CodePhone Number
E-mail
Father's (or guardian's) name:
First NameLast Name
Occupation:
Business phone:
Area CodePhone Number

Business address:

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

Cell phone:
Area CodePhone Number
E-mail
Student Information:
Is the biological mother Jewish?*
YesNo
Is the biological father Jewish?*
YesNo
Were there any conversions or adoptions in the family?*
YesNo
If Yes, who was the Rabbi?*
Additional comments: any educational concerns that will help us with your child:
Payment:
Early bird discount applied only to those applications submitted with full payment.
I would like to sponsor the Jewish education of another child for $1000.
I would like to contribute:
$36$72$180$360
Please call me to arrange a payment planPlease send me a scholarship application form
Total
$0.00

I would like to pay today: Full amount10% minimum: $0.00 $

Payment*

Credit Card Check

Postal / Zip Code

Country

*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:
ComputersHandymanOrganizationGraphic Design
Emergency File:
Doctor's name:*
First NameLast Name
Doctor's phone:*
Area CodePhone Number

Doctor's address:*

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

Allergies:
Medical Conditions:
Other:
P LEASE LIST BELOW TWO EMERGENCY CONTACTS :
Contact 1: Name, Phone, Relationship:*
Contact 2: 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:
Should be Empty:

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ENROLLMENT FORM

Student Information:

Payment:

Volunteer:

Emergency File:

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