Enrollment Form 2010-2011

Please PRINT this form, complete and send in with your payment to:   6 Rehoboth Rd., Flanders, NJ, 07836

Once we have received the registration form, we will send you the Parent Handbook with all the detailed information.

Child Information (if enrolling more than one child please copy and complete child info).

Child #1 First name ............................. Last Name ............................. Hebrew Name .............................

D.O.B. ......./......./....... Entering Grade ...........

My child's knowledge of Hebrew reading: Poor .......... Fair .......... Good ..........

Does your child have any special learning or behavioral needs? ...................................................................

..............................................................................................................................................................
__________________________________________________________________________________________

Family Information

Are the natural mother, maternal grandmother and father Jewish? Yes.......... No ..........

If no, please explain ................................................................................................................................

..............................................................................................................................................................

Have there been any conversions or adoptions in your family? Yes .......... No ..........

If yes, please explain ...............................................................................................................................

..............................................................................................................................................................
__________________________________________________________________________________________

Parent Information

Address ............................................................................... City ............................................ Zip.........

Father's Name ........................................................................................................................................

Phone: Home #...................................... Work #...................................... Cell #.......................................

E-mail Address: .............................................................................................

Mother's Name ........................................................................................................................................

Phone: Home #...................................... Work #...................................... Cell #.......................................

E-mail Address: .............................................................................................

Name of emergency contact ................................................................... Phone #....................................
__________________________________________________________________________________________

In the event of an emergency, The Chabad Hebrew School has my permission to arrange for any necessary first-aid or care for my child. I give permission for my child/ren to take class trips with the Chabad Hebrew School. I hereby hold harmless and release Chabad Hebrew School and its representatives from any liability regarding thereto. I take responsibility for any damage caused by my child/ren at the Hebrew School facility. I allow photos of my family to be used for any legitimate use.

I agree to pay the balance or make payment arrangements before the beginning of the school year for $585.00.
__________________________________________________________________________________________

Payment Options:

Make check payable to Chabad Jewish Center 
I am mailing One check for payment in full $.............................  or Charge my credit card #............................................................................................ Exp: ......./......./.......

Signature of pagent or legal guardian ............................................................................................................

Child/ren will be accepted into Chabad Hebrew School upon receipt of either one check of full payment or a valid credit card number.