New Students

Full Name*

First Name Last Name

Address*

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

Home

Area Code Phone Number

Father's Name*

First Name Last Name

Father's Hebrew Name if available

Father's Email*

Father's Cell #*

Area Code Phone Number

Is the Father Jewish?*

YesNo

Mother's Name*

First Name Last Name

Mother's Hebrew Name if available

Mother's Email*

Mother's Cell #*

Area Code Phone Number

Is the Mother Jewish*

YesNo

Marital Status of Parents*

MarriedDivorcedSeparated

Any conversions in the family?*

YesNo

If yes, please explain:

How did you hear about Chabad Hebrew School?*

FriendFacebookWebsite

If you were referred by a friend, please indicate their name:

First Child

#1 - Child's Name*

#1 - Child's Hebrew Name if available

#1 - Birth Date*

Month Day Year

#1 - Hebrew DOB* if not known, please indicate time of birth or whether before or after sunset

#1 - School attending* in the fall

#1 - Grade entering* in the fall

#1 - Is the child adopted?*

YesNo

#1 - List regular medications* enter NONE if not applicable

#1 - List Allergies to food or meds* enter NONE if not applicable

#1 - Need for an Epi-pen?*

YesNo

Are you registering a 2nd child?*

YesNo

Second Child

#2 - Child's Name*

#2 - Child's Hebrew Name if available

#2 - Birth Date*

Month Day Year

#2 - Hebrew DOB* if not known, please indicate time of birth or whether before or after sunset

#2 - School attending* in the fall

#2 - Grade entering* in the fall

#2 - Is the child adopted?*

YesNo

#2 - List regular medications* enter NONE if not applicable

#2 - List Allergies to food or meds* enter NONE if not applicable

#2 - Need for an Epi-pen?*

YesNo

Are you registering a 3rd child?*

YesNo

Third Child

#3 - Child's Name*

#3 - Child's Hebrew Name if available

#3 - Birth Date*

Month Day Year

#3 - Hebrew DOB* if not known, please indicate time of birth or whether before or after sunset

#3 - School attending* in the fall

#3 - Grade entering* in the fall

#3 - Is the child adopted?*

YesNo

#3 - List regular medications* enter NONE if not applicable

#3 - List Allergies to food or meds* enter NONE if not applicable

#3 - Need for an Epi-pen?*

YesNo

List name(s) of those (other than parents) authorized to pick up from school

Grades K-7 $1100 Tuition per child if registered by July 31, 2024
$1150 Tuition per child if registered after July 31, 2023
Security Fee: $50 per child

Early Bird Discount - $ 50 if registered by May 31, 2024.

$100 Deposit, per child, is due with registration by credit card and will be applied to tuition.

Tuition includes book fee.

By registering your child(ren) you are agreeing to the tuition payment schedule and your credit card will be charged accordingly.

# of children registering* $100 deposit will be charged to your credit card per student

Total

$0.00

Payment options for balance per student*

Payment in full by August 1 by credit card on fileTwo equal payments (August 1 and December 31) by credit card on fileI have spoken with the office regarding an alternative payment plan

Payment*

Credit Card

We accept Visa, MasterCard, American Express, Discover
Credit Card Number	Security Code
Name on Card
Expiration Month	Expiration Year

Billing Address

Street Address

City

State / Province

Postal / Zip Code

Country

To enroll your child(ren) in Chabad of Boca Raton Central Hebrew School all forms must be submitted with the required fees.

Enrollment is considered to be for the entire school year. The school cannot issue refunds or credits for illness, holidays, family vacations, or early withdrawal. In the event that the school is closed due to or resulting from a weather emergency or other unforeseen circumstances, there will be no make-up days, refunds or credits for days that school is not in session.

Upon processing a tuition payment, if sufficient funds are not available or the credit card is not approved, your account will be charged $25 for each transaction that could not be processed.

Parent(s) acknowledge that Chabad Hebrew School serves children who are able to function successfully in a group setting. If, in the judgement of the school's Director, the child is not able to function in a group setting, the parent may be asked to withdraw the child. In the event that the parent is requested to withdraw the child, the Director will work with the parent to identify possible alternative programs suitable for the child.

We give permission for the use of photographs of our child(ren) in print materials, on our website, social media and/or emails. Last names of children are never listed.

We give permission for our name and telephone number(s) to be included in any class list that may be distributed.

Does your child(ren) have any medical, developmental or behaviorial issue that we should know about?*

YesNo

If yes, please indicate which child and describe

I authorize the director or director's designee to seek appropriate medical care for my child, if necessary.

In case of emergency, when neither parent can be reached, give names of two people who will take responsibility for your child.

Emergency Contact #1 - Name*

First Name Last Name

Emergency Contact #1 - Cell Phone*

Area Code Phone Number

Emergency Contact #2 - Name*

First Name Last Name

Emergency Contact #2 - Cell Phone*

Area Code Phone Number

If parents cannot be reached and emergency medical advice is needed, permission is given to Chabad Hebrew School staff to phone my child's doctor.

In case of a medical emergency requiring immediate emergency care, I authorize the paramedics to take my child to the nearest hospital, if necessary. It is understood that I will hold Chabad of Boca Raton Central and Hebrew School harmless for the nature and outcome of any emergency medical treatment. It is also understood that I leave the decision of what constitutes an emergency to the sole direction of the staff.

Doctor*

Doctor Phone #*

Area Code Phone Number

Doctor Address*

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

I have provided information, consent, authorization and agreement where indicated, and the information I provided is accurate.

Type first and last name of parent completing this form, to be used as your electronic signature.*

First Name Last Name

Please send a confirmation email to:*

School Year 2024-2025

Child(ren)'s Parent Information

Child Information

Pick-up Authorization

Tuition & Payment

Enrollment Agreement

Medical and Developmental History

Medical Emergencies

Parent Electronic Signature

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