CHS Online Application Form

Student Information
Full Name*

First Name Last Name
Hebrew Name* If your child does not have a hebrew name please mark unknown
Birth Date*

Month Day Year
School Attending*
Grade Entering* (Upcoming Fall)
How would you describe your child's knowledge of basic Judaism?*
My Child* (Please select one)

Does not read Hebrew Recognizes letters of the Aleph Bet Can read Hebrew Slowly Can read Hebrew very well
Any considerations, such as learning disorder or difficulty, the school should be aware of: (confidential)
Parent Information

Home Address*

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

Subdivision (If applicable)
Home Phone*

Area Code Phone Number
Are the child's natural parents Jewish by birth?*

Yes No
If no, please explain:
Have there been any conversions or adoptions in your family?*

Yes No
If yes, Please explain:
Father's Name*

First Name Last Name
Father's E-mail*
Father's Cell*

Area Code Phone Number
Mother's Name*

First Name Last Name
Mother's E-mail*
Mother's Cell*

Area Code Phone Number
Emergency Information

Please list two emergency contacts
Contact 1 Name*

First Name Last Name
Contact 1 Phone*

Area Code Phone Number
Contact 1 Relationship*
Contact 2 Name*

First Name Last Name
Contact 2 Phone*

Area Code Phone Number
Contact 2 Relationship*
Health Insurance*

Please send a copy of your insurance card for our files
Emergency Care Agreement* I/we authorize any adult acting on behalf of Chabad 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 Hebrew School personnel will try, but are not required, to communicate with me prior to such treatment.

I Agree
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 Chabad Hebrew School activities.*

I Agree
Tuition

The tuition for each of the programs is as follows:

Please note that no child will be turned away due to lack of funds. Please contact us at 678-460-7702 to discuss any financial considerations.

Grades K-7: $590 + $40 Non Refundable Registration & Book Fee

**Chai Club members recieve a 10% discount

Refunds for children withdrawing from school before the end of the school year will be pro-rated up to February 1. Tuition refunds will not be granted to children withdrawing from school after February 1. There are no refunds or credits for days missed due to illness, holidays, or family vacations.
Tuition Options* Please select from the following tuition options. A full payment plan is required to attend Hebrew School.

8 Monthly Payments Full Payment Chai Club Member Full Payment Chai Club Member 8 Monthly Payments
Please consider supporting the Chabad Jewish Center

Unlike traditional synagogues, The Chabad Jewish Center does not ask for annual membership dues or require any building fund payments. Each Chabad Center is self-supporting and does not receive funding from Chabad-Lubavitch World Headquarters in New York. To help support the efforts of The Chabad Jewish Center, we have created different options for the community to partner with us: 1. Join our Chai Circle of Friends. By becoming our partner through the Chai Circle of Friends, you are committing to a monthly donation in a multiple of 18, or Chai, which means life in Hebrew. 2. Join our Annual Campaign with a generous pledge (your donation can be earmarked to any project or fund). Please consider supporting the Chabad Jewish Center, your donation, combined with everyone else’s, will allow us to continue serving the community’s spiritual needs and reach out like never before. Thank You!
I would like to join the Chai Circle of Friends with a Monthly Donation of: Your credit card will be billed each month for the following amount:

$18 USD $36 USD $54 USD $54 USD $72 USD $90 USD $108 USD $180 USD $360 USD
I would like to make a donation to the Annual Campaign of:

$250 USD $360 USD $500 USD $770 USD $1000 USD $3600 USD
Payment Information

Payment*

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Student Information

Parent Information

Emergency Information

Payment Information

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