Registration

Please fill out all fields in this form. If you have any questions or concerns you’d like to discuss with us, please call us at 818-802-8555. Please note that one registration form per child is needed.
Student Profile
Name*
First Name Last Name
Hebrew Name*
DOB*

Month Day Year
Gender

MaleFemale
School Attending*
Current Grade*
Hebrew Reading Proficiency

NoneSomewhatGood
Is the biological mother of this child Jewish?

YesNo
Have there been any conversions or adoptions in the maternal family history?

YesNo
If Yes, please explain:*
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.*
Parent Information
Father's Name*
First Name Last Name
Father's Phone*
Father's Email*
Mother's Name*
First Name Last Name
Mother's Phone*
Mother's Email*

Address*

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

All registrations must be accompanied with first month's tuition of $75 (Sibling $65)
Balance Payment Options*

Please charge this card monthly for all 9 monthsPlease charge the full balance the second month of schoolWill pay balance in cash or by check
Payment Amount*
Authorization & Consent
When our office receives this form, an appointment will be set up with our staff, who will then determine the eligibility of each student.
I/we allow Chabad Hebrew School permission to take my/our child/ren on outings and allow them to give emergency medical care as necessary.
I Accept*

I Accept
Name*
Initials*
Should be Empty:

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Educate Your Child... Educate a Generation

Student Profile