Educate your child... educate a generation!

ב"ה

Friendship Circle Hebrew School Registration

Child's Name*

First Name Last Name
Child's Hebrew Name:
Child's Birth Date*

Month Day Year
Help us figure out the Hebrew birthday!*

born during the day born in the evening born at dusk/sunset
Parents Information
Parent 1's Name*

First Name Last Name
Parent 2's Name*

First Name Last Name
Check which apply:*

Mother born Jewish Mother converted
Parent 1's E-mail*
Parent's 2 Email*
Home Phone*

Area Code Phone Number
Parent 1's Cell*

Area Code Phone Number
Parent 2's Cell*

Area Code Phone Number
Parent 1's Work phone

Area Code Phone Number
Parent 2's work phone

Area Code Phone Number

Parent 1 Address*

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

Parent 2's Address

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

Yes, I can volunteer! I can help with the following:
Emergency Contacts
Doctor's Name

First Name Last Name
Doctor's Phone

Area Code Phone Number
Emergency Contact*
Emergency Cell*

Area Code Phone Number
Emergency Home

Area Code Phone Number
Relationship to Student
Authorized to pick up

Emergency Contact Parents Other
Other Pick up:
Pick up's Number

Area Code Phone Number
Permission forms
I hereby give permission for my child to be transported to and from field trips, and to participate in them in all activities. I understand that during the course of Chabad Hebrew School my child can be hurt. I accept the risk of possible injury and authorize any member of the Chabad of the West Side staff to render any necessary first aid. Furthermore, in an emergency case, I hereby authorize Rabbi Chayim Alevsky or another staff member to have my child taken care of by a physician or other medical person in any way the situation calls for.
Transport/Emergency Care as listed above*

I give permission I don't give permission
Initial Here:*
I give permission to Chabad of the West Side, and those authorized by Chabad, to take photographs and to make recordings of my children and my family, and to use them in original or modified form in all media now or hereafter known, with or without my name or information about me, for the promotion, public education, and/or fundraising activities of Chabad of the West Side.
Media Authorization*

I give permission I don't give permission
Initial Here:*
I would like to receive news and updates from Chabad of the West Side by email. I understand that information I provide to Chabad of the West Side will be used according to its Privacy Policy and I can unsubscribe at any time.
Payment
$1,000 a year (Approx 30 classes)

Payment Schedule:

Deposit due at registration: $200
$400 due on September 1, $400 due on January 1
Payment Options
Payment Options
Total

$0.00

Payment

Credit Card

Credit Card Type
Credit Card Number	Security Code
Name on Card
Expiration Month	Expiration Year

Billing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Should be Empty:

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Parents Information

Emergency Contacts

Permission forms

Payment

Payment Options

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