Hebrew School 5786

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Medical Form Payment Plan Form
Child Information
Last Name*
First Name*
Hebrew Name (or type 'unknown')*
Gender*
Entering Grade*
Date of Birth*
Does Not Read HebrewRecognizes letters of the Alef-BetCan read Hebrew slowlyCan read Hebrew very well
GoodFairPoor
Family Information
YesNo
If no please explain
YesNo
If Yes please explain
Address and Information
Home Address*
City*
State*
Zip*
Subdivision*
Home Phone
Father
First Name
Email
Cell Phone #
Mother
First Name
Email
Cell Phone #
Emergency Contact
In case of emergency and the parents cannot be contacted please contact
Phone number
Relationship
Payment Information
$25
Please invoice mePaying by credit card below
Please invoice mePaying by credit card below
In the event of an emergency ח"ו The Chabad Hebrew School has my permission to arrange for any necessary first-aid or care by a licensed physician for my child while he/she is attending school.
I have completed the enrollment form and I have enclosed my registration fee and appropriate payment for my child(ren) to attend the Chabad Hebrew School. I agree to pay any balance prior to the start of the school year.
Electronic Signature*
Date*

My Products

Hebrew School registration$25.00

@ Hebrew School tuition (do not check if not paying now)$850.00

Total $0.00

Credit Card

First Name

Last Name

Credit Card Number

Security Code

Expiration Month

Expiration Year

Billing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Child Information