Registration

Address

Work Address

Work Address

Synagogue Affiliation
Student Information
Full Name*

First Name Last Name
Hebrew Name
Email
Birth Date*

Month Day Year
School*
Grade Entering*
Religious & Educational History
Previous Hebrew Education*
Were there any conversions and/or adoptions in the family?*

YesNo
What relation to the family?*
Where was the conversion performed?*
Who was the Rabbi who performed the conversion?*
Medical and Emergency Contact Information
Up to date with vaccinations?*

YesNo
Any special medical or other information, which we should be aware of including allergies?*
Family Physician*

First Name Last Name
Family Physician Phone Number*

Area Code Phone Number
Medical Insurance Co
Policy Number
Emergency Contact*

First Name Last Name
Emergency Contact Phone Number*

Area Code Phone Number
Relationship to Child*
Medical Release*

I hereby give consent to the administration of the Chevra Hebrew School to take whatever medical measures they deem necessary, at my expense, for my child in the event of a medical emergency.
Participation Waiver*

I hereby permit my child to participate in all school activities, and to join in class and school trips on and beyond school properties and use any transportation selected by the Chevra Hebrew School.
Payment Information
Tuition*

Full Tuition - $750Scholarship Request
Total

$0.00

Payment

Credit Card Paypal Check

Postal / Zip Code

Country

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Programs

Family Information