CHS REGISTRATION FORM 2023-2024 Student Information Full Name* First Name Last Name Hebrew Name* First Name Middle Name Birth Date* Month Day Year School* Previous Jewish Education Grade entering* Kindergarder 1st 2nd 3rd 4th 5th 6th 7th 8th 9th 2nd child Full Name, 2nd child First Name Last Name Hebrew Name, 2nd child First Name Middle Name Birth Date, 2nd child, Month Day Year Approx time of day born, 2nd child Approx time of day born School Grade entering,2nd child, Kindergarder 1st 2nd 3rd 4th 5th 6th 7th 8th 9th Previous Jewish Education, 2nd child 3rd Child Full Name, 3rd child First Name Last Name Hebrew Name, 3rd child First Name Middle Name Birth Date, 3rd child Month Day Year Approx time of day born, 3rd child School, 3rd child Previous Jewish Education, 3rd child Grade entering, 3rd child Kindergarder 1st 2nd 3rd 4th 5th 6th 7th 8th 9th Address* Street Address Street Address Line 2 City State / Province Postal / Zip Code Please Select United States Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan The Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Brazil Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile People's Republic of China Republic of China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Cote d'Ivoire Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Eswatini Ethiopia Falkland Islands Faroe Islands Fiji Finland France French Polynesia Gabon The Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati North Korea South Korea Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Islands Poland Portugal Puerto Rico Qatar Romania Russia Rwanda Saint Barthelemy Saint Helena Saint Kitts and Nevis Saint Lucia Saint Martin Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia Somaliland South Africa South Ossetia Spain Sri Lanka Sudan Suriname Svalbard Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tristan da Cunha Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam British Virgin Islands US Virgin Islands Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe Other Country Additional notable Information Please let us know if there are any allergies or other important information we need to be aware of. Parents Information Parent's Name* First Name Last Name Parent's Cell* Area Code Phone Number Parent 2 Name* First Name Last Name Parent 2 Hebrew Name Mother Jewish by:* BirthChoice (Orthodox conversion)Choice (Other Conversion) Parent 2 Cell* Area Code Phone Number E-mail* Best way to send Hebrew School updates:* Cell PhoneEmailHandout I am willing to assist in school activities, please contact me TUITION* 1200.00 for one student2280.00 for 2 students3360.00 for three students Total $0.00 I would like to pay today:Full amount$100.00 minimum$ Recurring Payment I would like to set up a recurring payment. Please contact me to arrange. Payment Credit Card We accept Visa, MasterCard, American Express, Discover Credit Card Number Security Code Name on Card 1 - January 2 - February 3 - March 4 - April 5 - May 6 - June 7 - July 8 - August 9 - September 10 - October 11 - November 12 - December Expiration Month 2023 2024 2025 2026 2027 2028 2029 2030 2031 2032 Expiration Year Billing Address Street Address Street Address Line 2 City State / Province Postal / Zip Code Please Select United States Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan The Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Brazil Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile People's Republic of China Republic of China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Cote d'Ivoire Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Eswatini Ethiopia Falkland Islands Faroe Islands Fiji Finland France French Polynesia Gabon The Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati North Korea South Korea Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Islands Poland Portugal Puerto Rico Qatar Romania Russia Rwanda Saint Barthelemy Saint Helena Saint Kitts and Nevis Saint Lucia Saint Martin Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia Somaliland South Africa South Ossetia Spain Sri Lanka Sudan Suriname Svalbard Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tristan da Cunha Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam British Virgin Islands US Virgin Islands Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe Other Country Authorized pickup and emergency contacts Authorized pickup Pickup number Emergency Contact Emergency number I hereby give permission for my child to be transported to and from field trips, and to participate in them in all Hebrew School activities. I understand that during the course of 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 Hebrew School staff to render any necessary first aid. Furthermore, in an emergency case, I hereby authorize Sarah Alevsky, Rabbi Chayim Alevsky or another staff member to have my child taken care of by a doctor or other medical person in any way the situation calls for. Permission Signature* I give permission to Chabad of the West Side, Chabad Family Programs and Chabad Hebrew School 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 Permission* I allow you to use my child's pictures for promotionDo not share my child's photos Media signature* Submit Should be Empty: This page uses TLS encryption to keep your data secure.