Registration

For more information e-mail [email protected]
Please submit 1 form per applicant
Parent Information
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 Information
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.
Authorizations for Pick-Up
Other than Parents
# 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.
Payment Information
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
Should be Empty:

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Parent Information

Student Information

Authorizations for Pick-Up

Payment Information