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Register Online

Please fill out this form as an initial registration for the CJC Hebrew School.
Student Information
Full Name*

First Name Last Name
Hebrew Name
Age*
Gender*

Male Female
Birth Date*

Month Day Year
Does your child have previous Jewish Education*

Yes No
If yes, please describe:
What school does your child attend?*
Grade entering:*
Synagogue affiliated with:*
Is the natural mother of the child Jewish?*

Yes No
Were there any conversions or adoptions in your family?*

Yes No
If yes, please describe:
Does your child read basic Hebrew?*

None Somewhat Well
Does your chld have any difficulty with general studies?
Parent Information
Father's Name*

First Name Last Name
Work Phone Number

Area Code Phone Number
Occupation*
Cell Phone Number*

Area Code Phone Number
E-mail*

Address*

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

Mother's Name*

First Name Last Name
Work Phone Number

Area Code Phone Number
Occupation*
Cell Phone Number

Area Code Phone Number
E-mail*

Address (if different than above)

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

Emergency Contact Information

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

First Name Last Name
Relationship to Child*
Phone Number*

Area Code Phone Number

Address*

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

Additional person authorized to care for child*

First Name Last Name
Relationship to Child*
Phone Number*

Area Code Phone Number

Address*

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

Child's physician or medical facility*
Phone Number*

Area Code Phone Number

Address*

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

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.
*

Accept Do Not Accept
Payment Information

Payment*

Credit Card Check

Postal / Zip Code

Country

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