CTeen HB - Hebrew High Registration Form
2016/2017

Student’s information

Name:

Hebrew name:

Male Female

Date of Birth: Month:
Day: Year:

Age as of 09/16:

Grade as of 09/16:

School:

Prior Hebrew education (if any):

Does your child read Hebrew?

Does your child write in cursive?

Does your child comprehend Hebrew?

Does your child have any learning difficulties? If yes, please describe:


Family Information

Address:

City: CA

Zip Code:

Telephone:

Father’s Information:

Name:

Cell:

Email:

Mother’s Information:

Name:

Cell:

Email:

Were there any conversions and/or adoptions in the family?

If yes, please describe:

Are the natural parents of the child/ren Jewish?
Father:
Mother:

Medical Information

Any medical conditions/allergies or related regarding your child we should be aware of?

Person to be contacted in case of an emergency:

Name:

Phone:

Relationship to child:

Health, trip and picture waiver.
As the parent(s) or legal guardian of the above child, I/we authorize any adult acting on behalf of the CTeen HB - Hebrew High to hospitalize or secure treatment for my child in the event of a medical emergency, I further agree to pay all charges for that care and/or treatment. It is understood that if time and circumstances reasonably permit, the CTeen HB - Hebrew High 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

I allow my child to be photographed while participating in the CTeen HB - Hebrew High activities and that these pictures may be used for marketing purposes.

Parent initials:

Date:

Cost:
Registration fee: $150
Books and supplies: $150

Tuition: $1,250

Please check your choice for method of payment:

Registration and Book fee (due at registration)

I will send a check for the registration and book fee: $300

Please charge my card for the registration and book fee: $300

Tuition

I will send a check for the full payment of $1,250

I will send four post-dated* payments of $312.50

Please charge my card for the full payment of $1,250

Please charge my card for four payments* of $312.50

Card type:

Card number:

Expiration - Month: Year:

3 (for Amex 4) digit security code:

*Sept 11 2016
Nov. 1 2016
Jan 1 2017
March 1 2017

Please make checks payable to Chabad of West Orange County.

Comments: