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Chabad Hebrew School Logo



Sunday 10 AM - 12:30 PM 


  Child 1 Child 2
Full Name
Hebrew Name
Date of Birth
School Attending
Grade Entering
 Referred by    
Mother's Info
Mother's Name
Hebrew Name
Mother's Email
Mother's Cell  
Mother's Work  
Business Name  
Additional Number  
Mother's Mailing Address
Home Address  
City, State  
Home Phone  
Father's Info
Father's Name
Hebrew Name
Father's Email
Father's Cell  
Father's Work  
Business Name  
Additional Number  
If parents live separately, please fill in father's mailing address
Home Address  
City, State  
Home Phone  
Synagogue affiliation, if any:
Does your child have any difficulties with general studies?  Yes  No
Were both the student and the mother born Jewish? Yes   No
If not, did the mother convert?  Yes  No
If yes, who performed the conversion? 
Emergency Contact
Home Number
Cell Number
To enhance our curriculum we have school events and programs.
Would you be willing to assist in event planning?      Yes     No
Would you like to be a class mother?    Yes    No

I hereby permit my child to participate in all activities, join in class and school trips on and beyond school properties. In case of an emergency, I hereby authorize the school to secure medical treatment for my child in any way that the situation may call for. I allow my child to be photographed while participating in Chabad Hebrew School activities and that these pictures may be used for marketing purposes.

Signature of Parent/Guardian: (Please enter your email address) 
Date:  (Please write the full date) 
Payment Options
 One time payment - $700 ($650 before June 30 2017)
 10 monthly payments of $70 ($50 will be deducted off 2nd payment if before June 30)
Payment Info
Credit Card Type  Visa Logo  Mastercard Logo  Amex Logo
Card Number
Exp. Date     
Security Code
Billing Address  
Billing Zip Code  
Comments (please include details)



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