Register - Beth Menachem Chabad of Newton

Student Information
Child 1:
Child's Name		Hebrew Name
Date of Birth		School
Grade Entering		Hebrew Reading Proficiency	None Somewhat Well
Previous Jewish Education	Yes No	Where?

Child 2: (if applicable)
Child's Name		Hebrew School
Date of Birth		School
Grade Entering		Hebrew Reading Proficiency	None Somewhat Well
Previous Jewish Education?	Yes No	Where?

Is the natural mother and maternal grandmother of the child Jewish? Yes No
Have there been any conversions or adoptions in the family? If Yes, please explain.

Parent Information
Father's Name		Email
Work Phone		Cell Phone
Mother's Name		Email
Work Phone		Cell Phone
Address		City
State		Zip

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.

Payment Information
Chabad Hebrew School Tuition for the complete year is $950 and includes registration fee and book fee.
I understand that a $100 deposit ONLY, that will be applied towards tuition, will be charged to my credit card along with my form submission.
Plan A - Payment in full		Plan B - Five additional monthly payments of $170

• The remaining tuition balance can be paid by check, mailed to Beth Menachem Chabad, 349 Dedham Street, Newton, MA 02459
Payment Method
Card Number		Expiration
CVV Code	What's This?	Billing Zip
Name on Card		Amount to Charge Card

Terms of Enrollment

As the parent(s) or legal guardian of the above child(ren), 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:

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