Hebrew School Register

Address*

Does your child read basic Hebrew?*

YesNo
If yes:

WellFairPoor
Does your child speak Hebrew?*

YesNo
If yes:

WellFairPoor
Does your child have any difficulties with his general studies?*

YesNo
If yes, please specify:
Family Information
Is the natural mother Jewish?*

YesNo
If yes,

by birthby conversion
Is the natural father Jewish?*

YesNo
If yes,

by birthby conversion
Are there any adoptions in the family? *

YesNo
If yes, please list:
Any questions or inquiries can be directed to our office: (916) 500-4522 or [email protected]

- Enrollment and acceptance in the Chabad Hebrew School is in no way a validation of one’s status as a Jew -
Emergency File
Doctor's Name

First Name Last Name

Doctor's Address*

Allergies (if any, please list)
Medical Conditions (if any, please explain)
Other
Please List Two Emergency Contacts:
Contact 1 Full Name

First Name Last Name
Contact 1 Phone Number

Area Code Phone Number
Contact 1 Relationship
Contact 2 Full Name

First Name Last Name
Contact 2 Phone Number

Area Code Phone Number
Contact 2 Relationship
Permission for Emergency Medical Treatment:

As the parent(s) or legal guardian(s), I/we authorize any adult acting on behalf of the Chabad of Roseville Hebrew School to hospitalize or secure treatment for my child. I further agree to pay for all charges for that care and/or treatment. It is understood that, if time and circumstances reasonably permit, Chabad Hebrew School will try to communicate with me prior to such treatment.

I/we hereby give permission for my child to attend all field trips and outings sponsored by Chabad of Roseville Hebrew School.
E-Signature of Parent or Legal Guardian*
Date*
Payment

$50 book fee - $500 tuition fee
Please charge me in*

1 payment - $5502 payments - $27510 payments - $55
Total

$0.00

Payment

Credit Card

We accept Visa, MasterCard, American Express, Discover
Credit Card Number	Security Code
Name on Card
Expiration Month	Expiration Year

Billing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

100% of the proceeds of this donation or payment benefit Chabad of Placer County.
Should be Empty:

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HEBREW SCHOOL REGISTRATION