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Educate your child... educate a generation!

ב"ה

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REGISTER
Please fill out ALL fields of this form. Confirmation of acceptance will be acknowledged after this registration form is reviewed and an acceptance email is received.
We look forward to a wonderful year of learning and growth.
If you have any questions, feel free to contact Tzippy Fuss, Chabad Hebrew School director, who will be happy to discuss any questions you may have.
Phone: 951-222-2005 Email: CLICK HERE
STUDENT INFORMATION
Child 1:
Full Name*
Birth Date*
MonthDayYear
Grade Entering in September*
Child 2:
Full Name
Birth Date
MonthDayYear
Grade Entering in September
Does your child(ren) read basic Hebrew?
YesNo
Previous Jewish Education?
YesNo
Are the natural parents of the child(ren) Jewish?*
BothMotherFatherNone
Were there any conversions or adoptions in your family?*
YesNo
If Yes - please explain
FAMILY INFORMATION
Mother's Name*
First NameLast Name
Mother's Cell*
Area CodePhone Number
E-mail*
Father's Name*
First NameLast Name
Father's Cell*
Area CodePhone Number
E-mail*

Address*

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

EMERGENCY CONTACT & MEDICAL INFORMATION
Persons to be contacted in case of an emergency when parents cannot be reached: (Please provide at least two contacts)
Emergency Contact 1:*
Emergency Contact 2:*
Is there any special medical or other information regarding your child(ren), of which we should be made aware?
Does your child(ren) have behavioral support in his/her regular school?*
YesNoPart Time
Authorization
I hereby give permission for my child(ren) to be transported to and from field trips, and to participate in them in all Chabad Hebrew School activities. I understand that during the course of Chabad Hebrew School my child(ren) can be hurt. I accept the risk of possible injury and authorize any member of the Chabad Hebrew School staff to render any necessary first aid. Furthermore, in an emergency case, I hereby authorize Tzippy Fuss, Rabbi Shmuel Fuss or another staff member to have my child(ren) 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 Hebrew School, 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 Hebrew School.
Media Authorization*
I give permission.I don't give permission
Initial Here:*
Payment
Full tuition: $529.00
In advance by August 31: $476.00
Includes registration fee, books and all supplies.
Discounts:
10% discount off for each additional child of the same family.
10% additional discount off your total tuition for each child of another family you successfully introduce to the school.
Please select:*
One Full Tuition PaymentFour equal payments charged on the first of the month September - December
A $50 non-refundable deposit is due at time of registration, per child (to be deducted from tuition).*
Total to be charged today:*
$

Payment*

Credit Card Paypal eCheck

Postal / Zip Code

Country

100% of the proceeds of this donation or payment benefit Chabad Jewish Community Center of Riverside.
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Early Bird Discount Ending August 29th!

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