Registration Form - Chabad of Contra Costa

Chabad of Contra Costa Hebrew School

Registration Form

2019 - 2020

We are currently accepting application forms for the 2019- 2020 school year. Please fill out ALL fields of this form. If you have any questions or concerns you'd like to discuss with us, please Email Chaya@JewishContraCosta.com.

At the bottom of the registration form please be sure to fill out the information needed for the $100 deposit, which can be paid online through this secure form.

Please note that one registration form per child is needed.

Please note: Your child is not registered in the Chabad Hebrew School until you receive a confirmation phone call or email.

We look forward to a wonderful year of learning and growth.

Student Information

Full Name

First NameLast Name

Hebrew Name

Gender

Birth Date

MonthDayYear

School

Grade Entering

Hebrew Reading Proficiency

NoneSomewhatWell

Previous Jewish Education

YesNo

If Yes, Where?

Parents Information

Father's Name

First NameLast Name

Mobile Number

Area CodePhone Number

E-mail

Mother's Name

First NameLast Name

Mobile Number

Area CodePhone Number

E-mail

Address

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

Jewish

Mother JewishFather Jewish

Conversions or Adoptions?

YesNo

If Yes, Please Explain

Emergency Information

Emergency Contact 1

First NameLast Name

Phone Number

Area CodePhone Number

Emergency Contact 2

First NameLast Name

Phone Number

Area CodePhone Number

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.

As the parent(s) or legal guardian of the above child, I / we authorize any adult acting on behalf of Chabad of Contra Costa 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 of Contra Costa 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 grounds and allow my child to be photographed while participating in Chabad of Contra Costa Hebrew School activities and that these pictures may be used for marketing purposes.

I Accept

Full Name

First NameLast Name

Initials

Payment Information

Payment Options

I would like to pay $650 full tuitionI would like to pay $100 depositSupporting Member $350 tuition2nd Semester $400

To become a supporting member of Chabad of Contra Costa Please click here

Scholarship Fund

I would like to make a $180 contribution

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

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