Child's Full Name*First NameLast NameHebrew Name*Grade entering in September 2022*Has any information changed for your family?If yes , please check the box and submit new information in the field below it. If not , please skip the next two fields.Please CheckParents Cell PhoneParents EmailEmergency ContactMedication / AllergiesNew or changed informationTuition Prices:*Please select:Pre-K & Kindergarten: $575Grades 1-2: $1050Grades 3-5 & 6: $1425Grade 7-8 (Mitzvah Corps): $1425Registration fee*$25 - Registration fee by 5/31/2022$125 - After 5/31/2022Tuition Assistance RequestedPlease explain your hardship and suggest payment terms that you can manageManadatory Security Fund*$100 Minimum Required$100$250$500$1000$1800Donate to the Scholarship Fund for families in need$36$100$360$500$1000$1250Total$0.00Yes, I'd like to donate the cost of processing this transaction by adding 3%Payment Plan*Pay in FullPayment Plan Requested: Payments will be divided over four monthsOther: Please complete the field below with a payment proposal you can managePayment TermsIf you checked 'other' aboveConsent:*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 NOT be charged at this time. It will be set-up based on your preferences checked above.Credit CardVisaMasterCardAmerican ExpressDiscoverCredit Card TypeCredit Card NumberSecurity CodeName on Card1 - January2 - February3 - March4 - April5 - May6 - June7 - July8 - August9 - September10 - October11 - November12 - DecemberExpiration Month2022202320242025202620272028202920302031Expiration YearBilling AddressStreet AddressStreet Address Line 2CityState / ProvincePostal / Zip CodePlease SelectUnited StatesAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanThe BahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChilePeople's Republic of ChinaRepublic of ChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCook IslandsCosta RicaCote d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonThe GambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern MarianaNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint BarthelemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSomalilandSouth AfricaSouth OssetiaSpainSri LankaSudanSurinameSvalbardSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTristan da CunhaTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamBritish Virgin IslandsUS Virgin IslandsWallis and FutunaWestern SaharaYemenZambiaZimbabweOtherCountrySubmitShould be Empty: This page uses TLS encryption to keep your data secure.