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Chabad Bethesda Hebrew School
Registration Form

Scholastic Year 2018-2019

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Dear parents: Please fill in this form in its entirety so that we may have a full record of your child. Please fill out a separate form for each child you wish to send. If you have any questions or comments, please feel free to contact us at the Hebrew School office: hebrew@shalomchabad.com or 240-370-8819. Thank you and looking forward to seeing you this year!

STUDENT INFORMATION

Last Name
First Name 
Hebrew Name

 

Home Address

Home Phone
Email

DOB / /
Age
School
Entering Grade

PARENT INFORMATION
Fathers Name
Hebrew Name

Occupation
Work Address

Work Phone
His Email
Mothers Name
Hebrew Name
Occupation
Work Address

Work Phone
Her Email

RELIGIOUS & EDUCATION INFORMATION
Synagogue Affiliation
Previous Hebrew School
Level of Hebrew Reading Proficiency:
None Basic Intermediate Advanced
Learning Disabilities? Yes No If yes, please describe:
Conversions or Adoptions in Family? Yes No If yes, please specify:
MEDICAL INFORMATION (Confidential)
Family Physician
Phone
Insurance Policy #
Up to date w/ vaccinations? Yes No Date of last tetanus:
Any special medical conditions?
Emergency Contact
Phone
Relation to Child
TUITION INFORMATION

Sunday Standard Program: 10am -12:30pm
Tuition for the year per child: $750, Registration & Book Fee: $50
Discount: 10% off - each additional child registered

Wednesday Supplemental Program: 4pm - 5:30pm
Tuition for the year per child: $450 Registration plus addtnl Supper option
Discount: 10% off - each additional child registered
Method of payment:
Full payment by Sep 1   1/2 by Sep 1, 1/2 by Jan 1    Special arrangement

Mode of payment:
Mail In Check Please make checks payable to 'Chabad of Bethesda' with 'Hebrew School Tuition' in memo line. All checks must be mailed to Chabad of Bethesda, 5713 Bradley Blvd, Bethesda, MD 20814.

Online Credit Card Payment Please fill out CC information below. Please note: an additional 3% fee will be assessed for CC payments)

 Online Credit Card Form
First name  Family name 

Billing Address  Apt # 

City  State   Zip 

Phone #   Email  

Purpose of Charge    Amount: $ 

Card Type   Card# 

Exp Date: /  CVV Code  (3 or 4 digits on back)

 
AGREEMENT

As the parent(s) or legal guardian of the above child, I/we authorize any adult acting on behalf of B-CC 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, B-CC 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 B-CC Hebrew School activities and that these pictures may be used for marketing purposes.

I Agree
Digital Signature (please type full name)  Date