HEBREW SCHOOL REGISTRATION We are currently accepting application forms for the 2012 school year. For NEW students only, please fill out ALL fields of this form. If you have any questions or concerns you'd like to discuss with us, please contact us. We look forward to a wonderful year of learning and growth. STUDENT INFORMATION First Name Last Name Hebrew Name D.O.B. Month Jan. Feb. Mar. Apr. May Jun. Jul. Aug. Sept. Oct. Nov. Date 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 School Grade Entering Grade Entering Kindergarten First Second Third Fourth Fifth Sixth Seventh Knowledge of Basic Judiasm None Somewhat Well Hebrew Reading Does not read Hebrew Recognizes letters of the Aleph-Bet Can read Hebrew slowly Can Read Hebrew well PARENT INFORMATION Father's Name Father's Cell Mother's Name Mother's Cell Address City, State, Zip City State Zip Home Phone Email Were there any conversions or adoptions in the family? Yes No If yes, please explain: GETTING TO KNOW YOU Please answer the following questions to help us know about your family and child so that we may best support your child's needs Whats your vision for your child's Hebrew School experience: What are the first 5 things that come to your mind when you think of "Judiasm" What makes you proudest about being Jewish? If you have a Hebrew School/day school education, please describe your experience: Is there any other information you would like to share about your family? How can we best support you in being part of your child's Hebrew School Education? How would you describe your child? Does your child have any particular hobbies or passions? Has your child had any behavioral or developmental difficulties or challenges in his/her regular school day? Is there any other information you would like to share/ have us know about your child? EMERGENCY INFORMATION Emergency Contact 1 Phone Emergency Contact 2 Phone 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 trips on and beyond school properties and allow my child to be photographed while participating in Chabad Hebrew School activities and that these pictures may be used for marketing purposes. I Accept Name: Initials: TUITION PAYMENT OPTIONS $50 discount per child with full payment by Aug. 31 for Semester 1 (14 Wed) & Semester 2 (20 Wed) I will pay for Semester 1&2: Child 1-$500, Child 2-$475, Child 3-$400 I will only pay for Semester 1 now: Child 1-$225, Child 2 & 3-$200 Optional pay for Semester 2 by Jan. 11: Child 1-$325, Child 2 & 3-$300 I will pay by check. Please mail check to Chabad of Solano County: 119 Briarwood Drive, Vacaville, CA 95688 I will pay by credit card below Name on card Card Type Select American Express Visa Mastercard Charge Amnt. Card Number Exp. Date Month 01 02 03 04 05 06 07 08 09 10 11 12 Year 2010 2011 2012 2013 2014 2015 2016 2017 2018 CVV Code 3 digits on back of card We look forward to a wonderful year of learning and growth! This page uses 128 bit SSL encryption to keep your data secure.
