Guardian Information
First Name
Last Name
Home Address
Zip
Phone
Email
Student Profile (For more then one, fill out both in the box. ie moshe, yosef)
Student First Name
Student Last Name
Age
Date of Birth
Current School
Grade Entering
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.
Tuition Options
Payment Information
Payment Method
Type
Visa
MC
Amex
Discover
Number
Expiration
Code
Use contact info above
Name
Billing Address
Billing Zip
Confirm and sign
As the parent(s) or legal guardian of the above child, 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 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 and that these pictures may be used for marketing purposes.
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