Registration - Chabad Jewish Center of NWBC

RE-REGISTRATION FORM: Parents of students previously enrolled, please click here for the shortened re-registration form.

Child's Full Name*

First NameLast Name

Hebrew Name:*

Birth Date*

MonthDayYear

Gender:*

MF

Indicate if child is biological or adopted:*

Indicate if biological parents and applicant child are Jewish by birth (JBB), conversion (C*) or non-Jewish (NJ)? *Certificate of conversion required

Father:*

JBBCNJ

Mother:*

JBBCNJ

Maternal Grand Mother:*

JBBCNJ

Child:*

JBBCNJ

School Currently Attending:*

Grade entering in September 2018*

Phone Number*

Area CodePhone Number

Child's E-mail

Father's Name:*

Father's Cell:*

Area CodePhone Number

Father's Email:*

Mother's Name:*

Mother's Cell:*

Area CodePhone Number

Mother's Email:*

Address*

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

Describe your family’s Jewish observance and your child’s knowledge of Jewish life and traditions:*

Level of Hebrew Knowledge:*

RecognizeReadWriteSpeak

Previous Hebrew School:*

Number of years attended:*

Name of Doctor:*

Phone Number*

Area CodePhone Number

Emergency Contact (other than parent) Name:*

Relation:*

Phone Number*

Area CodePhone Number

Cell Phone Number*

Area CodePhone Number

Confidential Information: Does child have any learning or physical disabilities/health problems? Other?*

Long-term medication:*

Allergies:*

Other important information we should know:*

Tuition Prices:*

Registration Fee*

$25 - Early-Bird Registration (Total tuition paid in full by 5/31/18)$125 - Standard Registration

Tuition Payment*

Pay in full at this timePayment Plan Requested: Payments will be divided over four monthsOther: Please complete the field below with a payment proposal you can manage

Tuition Assistance Requested

Donate to the Scholarship Fund for families in need

Total

$0.00

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 in full must be received at time of registration. For all other 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 Chabad of NW Bergen County 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.

Payment*

Credit Card

Credit Card Type
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