Jewish Enrichment Program Registration

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Please fill out this form as an initial registration for the Jewish Enrichment Program.

Confirmation of acceptance will be acknowledged only after this registration form is
reviewed and an acceptance letter is received.

Student Information


Male Female

Does you child read basic Hebrew? None Somewhat Well

Does your child speak/understand Hebrew? None Somewhat Well


What school does your child attend? Grade entering:
Are the natural mother and father of the child Jewish? Mother ____ Father _____  If not,

please explain ________________________________________________________________________________
Were there any conversions or adoptions in your family? Yes No
If yes, please describe:

Is child's maternal grandmother Jewish? Yes No

Have there been any conversions or adoptions in maternal grandmother's family? Yes No

If yes, please explain ___________________________________________________________________________

Any considerations, such as learning disorder or difficulty, the school should be aware of?
(Confidential):

Parent Information

Emergency Contact Information
Please list two contacts to be used in case of emergencies (other than your home and business numbers).










Please send a copy of your insurance card for our files.

Up to date with vaccinations? Yes No Date of last tetanus shot:
CONFIDENTIAL: Does your child have any allergies or other medical condition we should be aware of? If yes, please describe them and indicate special precautions or care needed.

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 child, I 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 prior to such treatment. I hereby give permission for my child to participate in all school activities, join in class and school trip on and beyond school properties and allow my child to be photographed while participating in Chabad Hebrew School activities.
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Initial here:

Refunds for children withdrawing from school before the end of the school year will be pro-rated up to February 1 provided that the school office is given 30 days written notice and does not include a $50 registration and book fee. Tuition refunds will not be granted to children withdrawing from school after February 1. There are no refunds or credits for days missed due to illness, holidays, or family vacations.
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Your FULL name here:

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