Camp Registration

Student Information

*First Name
*Last Name
Hebrew Name
*Gender
*Date of Birth
*Address
*City
*State
*Zip
Country
Home Phone
*School
*Grade
Note

Parent Information

Father


First Name
Last Name
Work Phone
Cell Phone
Email

Mother


First Name
Last Name
Work Phone
Cell Phone
Email

Marital Status

Have there been adoptions or conversions in the family?
If yes, please explain

Medical Information

Physician Name
Physician Phone
Insurance
Insurance Number
*Allergies
Medical Note

Emergency Information

	Name	Phone #	Relation
*Emergency 1
Emergency 2
Emergency 3

Enrollment Options / Tuition & Fees

Please check "Full Year" below and choose payment schedule.

Sessions

Full Year: Sep 8, 2024 - May 18, 2025

*Payment Schedule
Optional: Hebrew School Shabbat Dinner
Total Amount:

These fees will only be charged upon acceptance of your child.
No child will be turned away for lack of funds.

Payment Information

Only registration fee will be charged at this time.
Registration Fee
*Payment Type
*Card Number
*Expiration Date
*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

This page uses 128 bit SSL encryption to keep your data secure.