Student Registration

Full Name:*

First NameLast Name

Hebrew Name:*

Age:*

Birth Date:*

MonthDayYear

Gender:*

MaleFemale

Grade Entering:*

Tuition:*Plan A: Pay in Full
Plan B: Pay in Installments

To view and fill out the Chai Club partnership form, click here.

Full Name:

First NameLast Name

Hebrew Name:

Age:

Birth Date:

MonthDayYear

Gender:

MaleFemale

Grade Entering:

Tuition:Plan A: Pay in Full
Plan B: Pay in Installments

To view and fill out the Chai Club partnership form, click here.

Full Name:

First NameLast Name

Hebrew Name:

Age:

Birth Date:

MonthDayYear

Grade Entering:

Gender:

MaleFemale

Tuition:Plan A: Pay in Full
Plan B: Pay in Installments

To view and fill out the Chai Club partnership form, click here.

Address:*

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

Father's Name:*

First NameLast Name

Father's Occupation:*

Work Address:*

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

Father's Cell Phone Number:*

Area CodePhone Number

Father's E-mail Address:*

Is the biological father Jewish?*

YesNo

Mother's Name:*

First NameLast Name

Mother's Occupation:*

Work Address:*

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

Mother's Cell Phone Number:*

Area CodePhone Number

Mother's E-mail Address:*

Is the biological mother Jewish?*

YesNo

Any Conversions in the family?*

YesNo

If yes, please provide details:

Full Name:

First NameLast Name

Address:

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

Phone Number:

Area CodePhone Number

E-mail:

Full Name:

First NameLast Name

Address:

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

Phone Number:

Area CodePhone Number

E-mail:

Emergency Contact Name #1

First NameLast Name

Relationship to child:

Home Address:

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

Home Phone Number:

Area CodePhone Number

Work/Cell/Pager Number:

Area CodePhone Number

Physicians Name:

First NameLast Name

Physicians Phone Number:

Area CodePhone Number

Medical Insurance Company:

Group #:

ID #:

*

As the parent(s) or legal guardian of , I/we authorize any adult acting on behalf of Chabad of the Rivertowns 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.

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.

To view and fill in our Chai Club partner form Click here.

To view and fill out a tuition assistance form, Click here.

I would like to sponsor the education of another child for $1491

I would like to contribute toward the Jewish education of another child:

Total:

$0.00

Payment:

Credit Card Check

Postal / Zip Code

Country

*

I Accept

Full Name:*

First NameLast Name

Initials:*

We look forward to a wonderful year of learning and growth!

Student Registration:

Grandparents Information (for Nachas reports):

Emergency Information

Payment Information:

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