HS Registration e-Form - Neshama-Chabad Lubavitch of Manhattan Beach-Jewish Community Center
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Chabad Hebrew School
Registration Form

We are currently accepting application forms for the new 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 contact Shula 646-413-9092.

*Please note that one registration form per child is needed.

To download a printable version of this form, click on this link: Hebrew School Reg Forms PDF

STUDENT INFORMATION
First & Last Name Hebrew Name
Age D.O.B.
School Grade Entering
Address Apt.
City, State, Zip
City State Zip
Home Phone
Child's Cell Phone Child's Email
Name of Sibling: 1. Age:
2. Age:

PARENT INFORMATION
Father's Name Religion
Occupation Business Name
Address City, State, Zip
City State Zip
Email Cell
Facebook Name
Mother's Name Religion
Occupation Business Name
Address City, State, Zip
City State Zip
Email Cell
Facebook Name
Marital Status of Parents: Married Seperated Divorced - How long?

EMERGENCY INFORMATION
In case of emergency, when neither parent can be reached, please list two contacts who will take
responsibility for your child:
Emergency Contact 1 Relation to Child
Phone Business Phone
Emergency Contact 2 Relation to Child
Phone Business 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.

If parents cannot be reached and emergency medical advice is needed, permission is given to the
Hebrew School staff to phone my child’s doctor:

Doctor Phone
Address City, State, Zip
City State Zip
Doctor's Hospital Affiliation

In case of emergency requiring immediate emergency care, I authorize the paramedics to take my
child to the nearest hospital if necessary.

I Accept

PAYMENT PLAN

• Tuition per year: $750
• Book fee: $50
Tuiton can be paid in cash or by check.

I Will pay by Check
Checks should be made payable to Neshama.

I will pay by Credit Card

Charge Amount

Comments (optional)

Card Type
Card Number
Expiration
CVV Code

I understand that by submitting this form I am comitting to pay the above outlined tuition fees.

Name: Initials: Date:

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