Family InformationFamily Name*Mother's Name*Jewish Name (if available)Father's Name*Jewish Name (if available)Mothers Email* Mother's Cell*Mother is* Jewish by birth Jewish by choice Other Please explainFathers Email* Father's Cell*Father is* Jewish by birth Jewish by choice Other Address* Street Address City StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home PhoneWork PhoneMarital Status of Parents* Married Divorced Other Child InformationLocation* Long Branch @ Chabad (Sundays 9:45am - 12:15pm) Rumson @ 55 Center St. (Mondays 3:45pm-5:15pm) 1. Child Name* First Last Hebrew Name (if available)DOB*Grade Entering*2. Child Name First Last Hebrew Name (if available)DOBGrade Entering3. Child Name First Last Hebrew Name (if available)DOBGrade EnteringTuition InformationChabad Hebrew School Tuition is $600 per child. The $50 Registration Fee goes towards the Tuition Fee.Product NameNumber of children being registered---------------------One ChildTwo ChildrenThree ChildrenTotal $0.00 Payment InfoCredit Card* American ExpressDiscoverMasterCardVisaSupported Credit Cards: American Express, Discover, MasterCard, Visa Card Number Month010203040506070809101112 Year20252026202720282029203020312032203320342035203620372038203920402041204220432044 Expiration Date Security Code Cardholder Name CommentsEnrollment AgreementTo enroll your child(ren) in Chabad Hebrew School, all forms must be completed and sent in to the school. Your application will not be processed without the required forms and fees. Full payment due at the beginning of the school year, September 1, 2022. Enrollment is considered to be for the entire scholastic year. There will be no refunds even if the child is absent due to illness, holidays, vacations, and snow days, or should the parents decide to withdraw the child from the program. DISPOSITION The parent acknowledges that Chabad Hebrew School serves children who are able to function successfully in a group setting. If in the judgment of the school's Director, the child is not able to function in a group setting, the parent may be asked to withdraw the child. In the event that the parent is requested to withdraw the child, the Director will work with the parent to identify possible alternative programs suitable for the child. RELEASE OF INFORMATION AND PHOTOGRAPHS Parents allow for child(ren)'s picture to be used for internal PR mailing and website where name is not given. Parents allow for child(ren)'s photograph/name released to newspapers where the last name will not be given. If not, please contact us. By submitting and initialing this form, parents accept the terms outlined above. Both parents must initial.Mother's Initials*Date* MM slash DD slash YYYY Father's Initials*Date* MM slash DD slash YYYY Medical and Developmental HistoryDoes your child have any medical, developmental or behavioral issue that we should know about? Describe:Please list any medication your child is taking on a regular basis:Does your child have any allergies towards food or medication? If yes, please provide.Does your child have need for an epi-pen? Yes No If yes, please provide a current epi-pen and written permission to administer to Hebrew School at the beginning of the school yearMedical EmergenciesI authorize the director or director's designee to seek appropriate medical care for my child, if necessary.Emergency ContactIn case of emergency, when neither parent can be reached, give name of who will take responsibility for your child:Name* First Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Cell*HomeWorkRelationship to child*Medical AgreementIn case of medical emergency requiring immediate emergency care, I authorize the paramedics to take my child to the nearest hospital if necessary. It is understood that I will hold Chabad Hebrew School of Monmouth County harmless for the nature and outcome of any emergency medical treatment. It is also understood that I leave the decision of what constitutes an emergency to the sole direction of the staff (please sign)Mothers Initials*Date* MM slash DD slash YYYY Fathers Initials*Date* MM slash DD slash YYYY
