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Student Information
Full Name
First NameLast Name
Hebrew Name
Date of Birth
MonthDayYear
Gender
School
Grade (for 2019/20)
Prior Judaic knowledge or background
Parents Info
Mother's Full Name
First NameLast Name
E-mail
Home Phone Number
Area CodePhone Number
Cell Phone Number
Area CodePhone Number
Occupation

Address

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

Father's Full Name
First NameLast Name
E-mail
Home Phone Number
Area CodePhone Number
Cell Phone Number
Area CodePhone Number
Occupation

Addressif different then above

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

Marital Status
Have there been adoptions in the family?
YesNo
If yes, please explain
Have there beenconversions in the family?
YesNo
If yes, please explain
Best form of contact
EmailTextSocial Media
Medical Information
Physicians Name
Phone Number
Area CodePhone Number
Insurance name
Policy number
Allergies
Notes
Emergency Information
Emergency contact #1
First NameLast Name
Relationship
Phone Number
Area CodePhone Number
Emergency contact #2
First NameLast Name
Relationship
Phone Number
Area CodePhone Number
Enrollment Options/Tuition & Fees
Registration fee $65
Early bird registration $30 - till 6/20/19
Sibling discount 5%
Security fee $100/per family
Kindergarteners welcome discount $100
Family referral discount $50
With filling this form you will only be charged the registration fee
Sunday Program $630Wednesday Program $630
Payment options
Pay in full8 monthly payments to be charged to my card
For other arrangements email rabbi@chabadwestboynton.com
Total
$0.00

Credit Card Check

Yes! I’d like to be contacted about joining Chabad’s Chai Club membership!
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/our child, I/we 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/us prior to such treatment. I allow my child/ren’s photographs to be used in any print or digital publications or on social media.
I agree to the terms and conditions above
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May. 23, 2019

Lag B'omer Community BBQ