Registration - ChabadPlace.org

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

Parent Name*

First Name Last Name

Child's Full Name*

First Name Last Name

Hebrew Name:*

Birth Date*

Month Day Year

Gender: *

MF

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

Child:*

JBBCNJ

Mother:*

JBBCNJ

Maternal Grand Mother:*

JBBCNJ

Father *

JBBCNJ

Current School & Grade*

Previous Hebrew School: *

Years attended:*

Hebrew Letters & Language*

RecognizeReadWriteSpeak

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

Address*

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

Phone Number*

Area Code Phone Number

Father's Name: *

Father's Cell: *

Area Code Phone Number

Father's Email: *

Mother's Name:*

Mother's Cell:*

Area Code Phone Number

Mother's Email:*

Name of Doctor: *

Phone Number*

Area Code Phone Number

Emergency Contact (other than parent) Name:*

Relation: *

Phone Number*

Area Code Phone Number

Cell Phone Number*

Area Code Phone 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*

$50 - Registration Fee (by 6/1/2024)$200 - Registration Fee (6/2/2024)

Mandatory Security Fee* $100 Required Minimum

Tuition Assistance Requested

Donate to the Scholarship Fund for families in need

Total

$0.00

Yes, I'd like to donate the cost of processing this transaction by adding 3%

Payment Plan*

Payment in FullPayment divided over four months starting June '24Other: Please submit a proposed payment schedule

Payment Terms If you checked 'other' above

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* Payment will be processed manually based on your selection above.

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

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