CHABAD HEBREW SCHOOL REGISTRATION FORM

20 GREENRIDGE AVENUE WHITE PLAINS, NY 914-437-5762

• Sunday Program from 9:30-12:00.......................$975 (plus an additional $36 fee for supplies and snacks)
• Enrichment Wednesdays 3:45-5:15 (Sun. & Wed. class)....................$1625
• Special-ed program Mondays 3:15-5:45 (w/o lang.).....................$1200
• Preschool Jewish Enrichment Club Wednesdays 3:30-4:30(3s & 4s).....................$550
• Jewish Art & Cooking Club Tuesdays 4:45-6:00 (grades K-4 & Grades 5-8).........$350

Early Bird Special:
Pay in full by July 1, 2011 and receive the following special rates:
Sundays: $900; Sundays and Wednesdays $1525. 

Student's Name:

Students' Hebrew Name:

Birth Date:

Grade Entering:

Address:

Home Telephone Number:

e-mail:

School Name and Town:

Father's Name:

Father's Cell Number:

Father's email address:

Mother's Name:

Mother's Cell Number:

Mother's email address: 

Names and ages of other children in family:

ABOUT YOUR CHILD:

Does your child read basic Hebrew?

Previous Religious School Education:

Does your child have any learning difficulties with general studies? Please explain:

Is there anything you want us to know about your child that would help us to help him/her:

GENERAL:

Does either parent have any special resources or skills to offer our children or teachers?

We grant permission for our children to be photographed in an individual or group picture which may be used by the school for PR purposes (names of children are never released). Agree or Disagree:

Please list all names of people who are authorized to take child to and from school:

MEDICAL EMERGENCY INFORMATION:

In case of emergency, when neither parent can be reached, provide names of TWO people who will take responsibility for your child:

If parents cannot be reached and emergency medical advice is needed, permission is given to the Hebrew School staff to phone my child's doctor.  Agree or Disagree:

Doctor's Name:

Doctor's Address:

Doctor's Phone:

Doctor's Hospital Affiliation:

In case of medical emergency requiring immediate emergency care, I authorize to take my child to the hospital, if necessary. Agree or Disagree:

FURTHER MEDICAL INFORMATION:

Allergic reactions to medication:

Medication child is taking on a regular basis:

Any special medical circumstances or allergies:

PAYMENT INFORMATION:
Credit card
Name on card: 

Street address: 

City, State, Zip:

Phone Number:

Amount to charge: 

Card Type (Visa, Mastercard, Amex): 

Name on Card: 

Credit card number: 

Expiration Date: 

Security code:  

Checks can be mailed to: Chabad Hebrew School, 20 Greenridge Avenue, White Plains, NY 10605