Registration - Chabad of Hoboken & Jersey City

Child's Info

Child's Name*

First NameLast Name

Child's Hebrew Name*

Birth Date

MonthDayYear

Grade ENTERING*

Previous Jewish education?*

Parent's Info

Father's Name*

First NameLast Name

Father's Cell*

Area CodePhone Number

Father's Email*

Mother's Name*

First NameLast Name

Mother's Cell

Area CodePhone Number

Mother's Email

Address*

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

Are the natural father, mother and maternal grandmother of the child Jewish?*

Yes

Have there been any conversions or adoptions in the family?*

No

Did someone refer you? how did you find out about our program?*

Medical & Terms

Emergency Contact 1*

Phone Number

Area CodePhone Number

Emergency Contact 2:*

Phone Number

Area CodePhone Number

Physician's Name

First NameLast Name

Physician's Number

Area CodePhone Number

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.*

Terms of Agreement*

As the parent(s) or legal guardian of the above child, I/we authorize any adult acting on behalf of Chabad Hebrew School to hospitalize or secure treatment for my child, I further agree to pay all charges for that care and/or treatment. It is understood that if time and circumstances reasonably permit, Chabad Hebrew School personnel will try, but are not required, to communicate with me prior to such treatment. I hereby give permission for my child to participate in all school activities, join in class and school trips on and beyond school properties and allow my child to be photographed while participating in Chabad Hebrew School activities and that these pictures may be used for marketing purposes.

Amount to Charge $150 for deposit - avail for full price only. the remainder will be charged over 4 months; $880 early bird rate (until Jul 14); $950 - regular rate; $1000 (after aug 18) Sibling Discount minus 5% off each childs fee

$ USD

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