*Last Name
*First Name
Hebrew Name
*Gender Male Female
*Date of Birth
*Address
*City
*State
*Zip
Country
*Home Phone
*School
*Grade Entering
Note
*Physician Name
*Physician Phone
*Insurance
*Insurance Number
Allergies
Medical Note
*Title --Select Title-- Mr. Dr.
Work Phone
*Cell Phone
*Email
*Title --Select Title-- Mrs. Ms. Dr.
Marital Status --Select -- Married Separated Divorced Single Widow/er
Affiliation --Select -- None Chabad Temple Torah Shaarei Shalom
Have there been adoptions or conversions in the family?
If yes, please explain
Name Phone # Relation
*Emergency 1
*Emergency 2
Please choose enrollment options
*Tuition --Select-- Sunday Wednesday Wednesday
Total Amount:
These fees will only be charged upon acceptance of your child
Only registration fee will be charged at this time.
Registration Fee
*Card Type --Card Type-- Visa MC
*Card Number
*Expiration Date --Month-- 01 02 03 04 05 06 07 08 09 10 11 12 --Year-- 2025 2026 2027 2028 2029 2030 2031 2032 2033 2034 2035 2036 2037
*Security Code
Use Information above
*Name on Card
*Billing Address
*Billing Zip code
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 agree to the terms and conditions above
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