Hebrew School Enrollment 5785 - ChabadBocaBeaches.com

Family Info
Father's Name*

First Name Last Name
E-mail*
Mobile*
Is the father Jewish?*

YesNoYes, Converted
Mother's Name*

First Name Last Name
E-mail*
Mobile*
Is the mother Jewish?*

YesNoYes, Converted

Child Primary Address*

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

Marital Status of Parents *

SingleMarriedDivorcedWidowed
Child Information
Number of children being registered:*
Child 1:*

First Name Last Name
Hebrew Name
Birth Date*

Month Day Year
Please indicate time of birth:*

Before sunsetAfter sunsetUnknown
School child is attending in the fall*
Grade child is entering in the fall *
Is child adopted?*

YesNo
List any medications child is currently:*
List any allergies to food or medications:*
Does the child need an epi pen? *

YesNo
Does your child have any medical, developmental or behavioral issues that we should know about?*
Hebrew Letters & language skills*

RecognizeReadWriteSpeak
Consent:*

1. PARENTAL CONSENT: I hereby give consent for my child to participate in all activities at Chabad Hebrew School unless I advise you otherwise in writing.2. PAYMENT AND CANCELLATION: Payment must be received at time of acceptance. For all payment arrangements, a payment schedule must be coordinated with our office and post-dated checks submitted at time of registration. Hebrew School tuition is non-refundable.3. MEDICAL CARE: In case of emergency, I hereby give permission to the physician selected by the Hebrew School Director, to hospitalize, to secure proper treatment for and to order injection, anesthesia, or other procedure deemed necessary for my child by an M.D. as named on this form or if unavailable another M.D.. Every effort will be made to contact the parent / guardian and emergency contacts first. Should it be necessary for the well being of the student to utilize outside medical or dental services all expenses involved will be paid for by the parent. To the best of my knowledge, my child is in good health and I will notify Chabad if he/she is exposed to any infectious diseases.4. IMAGES, ETC.: Permission is hereby given to use in promoting Hebrew School and in other ventures directly relating to Chabad (i) digital, photographic and video images or likenesses of student; audio of student; and (ii) statements, articles, names, music, art, photographs, audio recordings, films and videos created by student or originating from Hebrew School or related activity.5. INDEMNIFY & HOLD HARMLESS: I further release and agree to indemnify and hold harmless Boca Beach Chabad and its officers, servants or assigns from any liability concerning our child’s involvement in Hebrew School activities and further agree that the use of any premises during Hebrew School is made at the risk of the registrant.
Child 2:*

First Name Last Name
Child 2: Hebrew Name*
Child 2: Birth Date*

Month Day Year
Child 2: Please indicate time of birth:*

Before sunsetAfter sunsetUnknown
Child 2: School child is attending in the fall*
Child 2: Grade child is entering in the fall*
Child 2: Is child adopted?*

YesNo
Child 2: List any medications child is currently:*
Child 2: List any allergies to food or medications:*
Child 2: Does the child need an epi pen?*

YesNo
Child 2: Does your child have any medical, developmental or behavioral issues that we should know about?*
Child 2: Hebrew Letters & language skills*

RecognizeReadWriteSpeak
Child 3: Name*

First Name Last Name
Child 3: Hebrew Name: *
Child 3: Birth Date*

Month Day Year
Child 3: Please indicate time of birth:*

Before sunsetAfter sunsetUnknown
Child 3: School child is attending in the fall*
Child 3: Grade child is entering in the fall*
Child 3: Is child adopted?*

YesNo
Child 3: List any medications child is currently:*
Child 3: List any allergies to food or medications:*
Child 3: Does the child need an epi pen?*

YesNo
Child 3: Does your child have any medical, developmental or behavioral issues that we should know about?*
Child 3: Hebrew Letters & language skills*

RecognizeReadWriteSpeak
Emergency Contact Information
Emergency Contact Full Name*

First Name Last Name
Emergency Contact Cell Phone*
Please send a confirmation email to:*
Payment & Agreement Information

Registration fee: $50 (to be included in tuition)

Total tuition is $1,250 per child.
Tuition payment will not be processed until registration is confirmed.
Child 1 Payment Plan:

1: Full payment upon acceptance.2: Tuition collected in two payments: half upon acceptance and half 4 months following.
Child 2 Payment Plan:

1: Full payment upon acceptance.2: Tuition collected in two payments: half upon acceptance and half 4 months following.
Child 3 Payment Plan:

1: Full payment upon acceptance.2: Tuition collected in two payments: half upon acceptance and half 4 months following.
Total (tuition payment will not be processed until registration is confirmed):

$0.00

Payment

Credit Card

We accept Visa, MasterCard, American Express, Discover
Credit Card Number	Security Code
Name on Card
Expiration Month	Expiration Year

Billing Address

Street Address

City

State / Province

Postal / Zip Code

Country

Should be Empty:

Family Info

Child Information

Emergency Contact Information

Payment & Agreement Information