Gan Chabad Application Form

Student Information
Name of Student*

First Name Middle Name Last Name
Hebrew Name*
Current Age*
Date of Birth*

Month Day Year
Gender*

FemaleMale

Home Address*

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

Home Phone*

Area Code Phone Number
Family Information
Father/Guardian's Information
Father's Name*

Prefix First Name Last Name
Father's Hebrew Name
Father's Occupation*
Father's E-mail*
Father's Cell Phone*

Area Code Phone Number
Father's Work Phone*

Area Code Phone Number
Mother/Guardian's Information
Mother's Name*

Prefix First Name Last Name
Mother's Hebrew Name
Mother's Occupation*
Mother's E-mail*
Mother's Cell Phone*

Area Code Phone Number
Mother's Work Phone

Area Code Phone Number
Family History
Are both the father and mother of child Jewish?*

YesNo
Was any parent or grandparent born not Jewish?*

YesNo
Marital Status*

MarriedSingleDivorcedWidowed
Siblings Information
Name

First Name Last Name
Birth Date

Month Day Year
School
Name

First Name Last Name
Birth Date

Month Day Year
School
Do you have any other children that are preschool age?*

YesNo
Are you currently on any other wait lists at another daycare?*

YesNo
Application Details
Infant Bayit Class: Ages 12 months - 18 months

Toddler Nitzanim Class: Ages 18 months- 2.5 years old (Child must be able to walk independently to join the toddler class)

Preschool Perachim Class: Ages 2.5 years to 4 years old
Class*

InfantToddlerPreschool
Admission Dates* These dates are based on possible availability in the infant room. Note that children typically graduate from the infant program to the toddler program at approximately 18 months.

Mar. 2024 - Aug. 2025Aug. 2024 - Aug. 2025Sept. 2024 - Aug. 2025Oct. 2024 - Aug. 2026Nov. 2024 - Aug. 2026Jan. 2025 - Aug. 2026
Admission Dates*

Sept 2023-August 2024
Age of Child upon admission date*
Program*

Monday-Friday 8:00am-6pm
Registration Fee:*

$250 Infant Class Registration Fee
Registration Fee:*

$94.50 Toddler/Nursery Class Registration Fee
Deposit* Deposit will be applied towards the last months' tuition payment.

$1346.62
Total

$0.00
Please understand that your child is not accepted until you receive email confirmation from our admin team. Your registration fee and deposit will be processed upon acceptance.

Registration Fee and Deposit are non-refundable.
Please note that photos taken during school/camp may be used for promotional or publicity purposes.

Payment

Credit Card

We accept Visa, MasterCard
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

Comments
Name of Applicant*

First Name Last Name
Relationship to Child*
How did you hear about us?

Search Engine/ OnlineFacebookOutdoor SignUptown Chabad ProgramsFriends/ Family
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Student Information

Family Information

Application Details