Register - Chabad of Bethesda

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