Student Profile
First Name
Last Name
Hebrew Name
Gender
DOB
School
Grade Entering (Sept. 2015)
Does your child read basic Hebrew?
Parent And Background Information
Mother's Information
Full Name
Address
City, State, Zip
Home Phone Number
Cell Phone
E-mail Address
Father's Information
Full Name
Address
City, State Zip
Home Phone Number
Cell Phone Number
E-mail Address
General Family Background Information
Is the biological mother of the
child(ren) Jewish?
Yes No
Are you, or any family members, affiliated with any other synagogues or Jewish organizations?

Yes No

If yes, please specify:

Have there been any conversions or adoptions in the maternal family history?

Yes No
If yes, please explain:

Emergency Contact Information - In Addition To Parents
First Name
Last Name
Relationship to Child(ren)
Telephone Number
Address
City, State, Zip Code

Payment Options
Name on Card:
Card Type
Card Number
Exp. Date
CCV Number (on back of card)
Payment Amount

Once our office receives this form an appointment will be set up with our staff, who will then determine the eligibility of each student.

I allow Chabad Hebrew School permission to take my child/ren on outings and allow them to give emergency medical care as necessary.

I Accept

Full Name: