Registration

For more information e-mail [email protected]

Please submit 1 form per applicant

Father's Name*

PrefixFirst NameLast Name

Father's E-mail*

Father's Cell Phone*

Area CodePhone Number

Father's Work Phone

Area CodePhone Number

Mother's Name*

PrefixFirst NameLast Name

Mother's E-mail*

Mother's Cell Phone*

Area CodePhone Number

Mother's Work Phone

Area CodePhone Number

Parent's Marital Status*

Is the biological mother of the child Jewish?*

YesNo

Were there any Jewish conversions in your family?*

YesNo

If yes, please provide details:

Were there any adoptions in your family?*

YesNo

Does your family have membership with a Synagogue?*

YesNo

If yes, please specify:

Emergency Contact Name*

PrefixFirst NameLast Name

Emergency Contact E-mail*

Emergency Contact Cell Phone*

Area CodePhone Number

Student's Full Name*

First NameLast Name

Hebrew Name*

Age*

Grade*

School*

Birth Date*

MonthDayYear

Gender*

FemaleMale

Home Phone Number*

Area CodePhone Number

Allergy or Health Information

Does your child's allergies require the use of an Epi Pen?*

YesNo

Does your child have any learning or behavioral needs?*

YesNo

If yes, please specify.

Does your child have a diagnosis?*

YesNo

If yes, please specify.

Has your child attended Hebrew School in the past?*

YesNo

Does your child read basic Hebrew?*

YesNo

If yes, how well?

Program Options:*

In person @ Chabad Sunday 10:30 am- 12:00 pmVirtual on zoom Wednesday 4:30 pm- 6:00 pmPods @ home- minimum 5 children within 2 school gradesI am a Pods @ home host -minimum 5 children within 2 school grades (10% off)Virtual 1 on 1 Hebrew reading instruction for ages 0-120 (included in options 1-3)

Click Here for Bat Mitzvah classes

Click Here for Bar Mitzvah classes

*All options include 15 minute weekly one on one he session.

Pods InformationList names/ages of children, the host's, location, the day of the week and the time.

Total

$0.00

Please note that photos taken during school may be used for promotional or publicity purposes.

# 1 Full Name

First NameLast Name

Phone Number

Area CodePhone Number

Relationship to Child

#2 Full Name

First NameLast Name

Phone Number

Area CodePhone Number

Relationship to Child

Child will only be released to individuals listed in this section unless otherwise indicated in writing by parents/guardian.

Book fees are included.

A tax deductible donation receipt will be issued for the full amount.

Please note: There are no refunds or make-up classes for illness or family vacations.

Payment:*

Credit Card

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

Billing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Comments

Parent Information

Student Information

Authorizations for Pick-Up

Payment Information