Register Online

Please fill out this form as an initial registration for the CJC Hebrew School.

Full Name*

First NameLast Name

Hebrew Name

Age*

Gender*

MaleFemale

Does your child have previous Jewish Education*

YesNo

If yes, please describe:

What school does your child attend?*

Grade entering:*

Synagogue affiliated with:*

Is the natural mother of the child Jewish?*

YesNo

Were there any conversions or adoptions in your family?*

YesNo

If yes, please describe:

Does your child read basic Hebrew?*

NoneSomewhatWell

Does your chld have any difficulty with general studies?

Father's Name*

First NameLast Name

Work Phone Number

Area CodePhone Number

Occupation*

Cell Phone Number*

Area CodePhone Number

E-mail*

Address*

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

Mother's Name*

First NameLast Name

Work Phone Number

Area CodePhone Number

Occupation*

Cell Phone Number

Area CodePhone Number

E-mail*

Address (if different than above)

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

Emergency Contact (other than parent)*

First NameLast Name

Relationship to Child*

Phone Number*

Area CodePhone Number

Address*

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

Additional person authorized to care for child*

First NameLast Name

Relationship to Child*

Phone Number*

Area CodePhone Number

Address*

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

Child's physician or medical facility*

Phone Number*

Area CodePhone 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.

*

AcceptDo Not Accept

Method of Payment*

Payment in Full $475 Early Bird Pricing if paid in full by July 12 includes tuition, registration & book fee.Payment in Full after July 12 $525 includes tuition, registration & book fee.

*

I, do hereby state that I will pay Hebrew School tuition of $475.00 to Chabad Jewish Center Greater S. Petersburg.

Comments/Questions:

Payment*

Credit Card Check

Postal / Zip Code

Country

Student Information

Parent Information

Emergency Contact Information

Payment Information