Student Registration

Hebrew School 2022/23- 5783
(Do you know of a new family looking for a Hebrew School? Refer them to Chabad and receive a $100 tuition credit)
*Registration received after August 1st incur a late fee of $100
Student Registration:
Number of Children Being Registered:*
Student #1 Profile
Full Name:*
First NameLast Name
Hebrew Name:*
Age:*
Birth Date:*
MonthDayYear
Gender:*
MaleFemale
Does your child have an IEP? If yes, please email it in.*
YesNo
Grade Entering:*
Track Selection:(choosing this track does not bind you for the entire year. You can choose a different track if your comfort level changes)
In PersonVirtualPods (create your own - 5 or more children, parents are responsible to form their own pods of similar ages)
Tuition:*Plan A: Pay in Full Plan B: Pay in Installments
To view and fill out the Chai Club partnership form, click here.
Student #2 Profile
Full Name:
First NameLast Name
Hebrew Name:
Age:
Birth Date:
MonthDayYear
Gender:
MaleFemale
Does your child have an IEP? If yes, please email it in.
YesNo
Grade Entering:
Track Selection:
In PersonVirtualPods (create your own - 4 or more children)
Track Selection:(choosing this track does not bind you for the entire year. You can choose a different track if your comfort level changes)
In PersonVirtualPods (create your own - 5 or more children, parents are responsible to form their own pods of similar ages)
Tuition:Plan A: Pay in Full Plan B: Pay in Installments
Student #3 Profile
Full Name:
First NameLast Name
Hebrew Name:
Age:
Birth Date:
MonthDayYear
Grade Entering:
Gender:
MaleFemale
Does your child have an IEP? If yes, please email it in.
YesNo
Track Selection:(choosing this track does not bind you for the entire year. You can choose a different track if your comfort level changes)
In PersonVirtualPods (create your own - 5 or more children, parents are responsible to form their own pods of similar ages)
Track Selection:
In PersonVirtualPods (create your own - 4 or more children)
Tuition:Plan A: Pay in Full
Plan B: Pay in Installments
Payment Information:

Address:*

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

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
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
Any Conversions in the family?*
YesNo
If yes, please provide details:
Grandparents Information (for Nachas reports):
We would love to send updates about your child to their grandparents throughout the year.
Paternal
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:
Maternal
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 Information
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.
Payment Information:
To view and fill out a tuition assistance form, Click here.
I would like to sponsor the education of another child for $1591
I would like to contribute toward the Jewish education of another child:
$36$72$180$360
Total:
$0.00

Payment:

Credit Card

Credit Card Type
Credit Card Number	Security Code
Name on Card
Expiration Month	Expiration Year

Billing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

*
I Accept
Full Name:*
First NameLast Name
Initials:*
How did you hear about our program?
We look forward to a wonderful year of learning and growth!
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Student Registration:

Grandparents Information (for Nachas reports):

Emergency Information

Payment Information: