Registration

Family Name

Home Number

Home Address

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

Mother's Name

First Name Last Name

Mother's Hebrew Name

Mother's Number

Mother's Email

Father's Name

First Name Last Name

Father's Hebrew Name

Father's Number

Father's Email

I would like to sign up my child for Hebrew School program

Child's Name*

First Name Last Name

Child's Hebrew Name

Grade Started in Sept 2024

Date of Birth

Month Day Year

Any learning issues with general studies? (State difficulty and what is being done to help)

Is the biological mother of the child Jewish?

YesNo

Is the mother's mother Jewish?

YesNo

Is the biological father of the child Jewish?

YesNo

Is the father’s mother Jewish?

YesNo

Have there been any conversions or adoptions in the family history?

YesNo

If yes please include all backup information & documentation.

Please note all conversions must be made through a registered Beth Din that is certified by the Israel Rabbinate.

Notes:

Special instructions (allergies, psychological or medical conditions, medications currently being taken, dietary requirements etc...)

Physician's Name

Physician's Number

I hereby give permission, in the event of an emergency, for the Director, the Acting Director, or the Teacher at Chabad of Mt. Olive to take whatever steps maybe necessary for the medical care of my child(ren),

I understand that unless there is a need for immediate action, the order of the steps taken will follow, but will not be limited to, the outline below:

1. The parent/Guardian will be called.

Note: If the parent/guardian is unavailable, the emergency contact person designated by the parent/guardian will be called.

2. Child's physician will be called.

3. If these efforts are unsuccessful the following steps will be taken (order may vary depending

on the situation):

a. Another physician will be called.

b. The child will be taken to the nearest emergency room accompanied by a staff member.

c. An ambulance will be called to take the child to the nearest emergency room accompanied by a staff member.

In the event of an emergency, if I cannot be reached, I give consent for a Chabad staff member to transport my child to the nearest emergency facility, or to have my child transported by ambulance.

I give consent to any emergency facility and physician to administer any necessary medical treatment to my child as the situation may warrant it.

Parent Initial

Parent Name

Date

Two Payment Options:
1) One time payment
2) Installments - $50 to be paid upon acceptance, with head checks of $550 to be paid over the next four months

No one will be turned away due to lack of funds.
Contact Rabbi Shusterman by email for any questions regarding payment plan. [email protected]

Total

$600.00

I would like to pay today:Full amount$50.00 minimum$

Yes, I'd like to donate the cost of processing this transaction by adding 3%

Payment

Credit Card

We accept Visa, MasterCard, American Express, Discover
Credit Card Number	Security Code
Name on Card
Expiration Month	Expiration Year

Billing Address

Street Address

City

State / Province

Postal / Zip Code

Country

Family Information

Student Information

General Information

Medical Information

Payment Information