Boys & Girls Ages 5-11 years Student Profile Last Name First Name Hebrew Name Gender Age DOB Month Jan. Feb. Mar. Apr. May Jun. Jul. Aug. Sept. Oct. Nov. Nov. Dec. Date 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 School Grade Entering Grade Entering Kindergarten First Second Third Fourth Fifth Sixth Seventh Eighth Hebrew Reading Proficiency None Somewhat Well My Child knows the Hebrew Alphabet Yes No If he/she attended prior Hebrew School please indicate where. Parent/Guardian Information Parental Status Married Divorced Single Are there any conversions in the family? Is Mother Jewish? Is Father Jewish? Address, City and Zip Home Phone Father's Name Father's Occupation Father's Cell Father's Email Mother's Name Mother's Occupation Mother's Cell Mother's Email Emergency Information Emergency Contact 1 Phone Emergency Contact 2 Phone Doctor's Name Doctor's Phone Number Medical Insurance Company Policy Number 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. Optional: Grandparents Information so we can share the "Nachas" Name Phone Email Address I will be bringing my child I will have someone else bring my child Name of person Phone of person I will be picking up my child after Hebrew School at 12 Noon I will have someone else pick up my child after Hebrew school Name of person Phone of person Registration Payment Agreement Tuition per child: We know that the challenges of Covid may make full payment difficult at this time. Please contact Rabbi Yossi Baitelman at 818-508-6633 regarding any changes to payment you need and we will do our best to accomodate. Method of Registration payment: Credit Cards Only Tuition Weekly Payment $40 Tuition Monthly Payment $160 Registration Payment Name on Credit Card CC Type Please Select Visa Mastercard Amex Discover Card Number Billing Address City, State, Zip CVV Exp Date Amount to be charged now: $ As the parent(s) or legal guardian of the above child, 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 Hebrew School personnel 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 school activities, join in class and school trips on and beyond school properties and allow my child to be photographed while participating in Chabad Hebrew School activities and that these pictures may be used for marketing purposes for our Hebrew Enrichment Program. I Accept Name: Initials: Date: I hereby give permission for my child to participate in all school activities, join in class and school trips on and beyond school properties and allow my child to be photographed while participating in Chabad Hebrew School activities and that these pictures may be used for marketing purposes for our Hebrew Enrichment Program. I accept Name: Initials: Date: We look forward to a wonderful year of learning and growth! This page uses 128 bit SSL encryption to keep your data secure.
