Registration Form 5785 - ChabadofSummerlin.com

Student Information:
Student Name*

First Name Middle Name Last Name
Hebrew Name
Is this child adopted:*

YesNo
Birth Date

Month Day Year
Age*

Address*

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Home Phone Number*

Area Code Phone Number
What school does your child attend*
Grade entering Fall 2024*
Does your child have an IEP / Special Needs?*

If the answer is YES please attach a copy of the IEP so we can have a follow up meeting
Does your child have any difficulty with his/her general studies?*
If you answered YES to the above question please specify
Synagogue Affiliation
Previous Hebrew /Jewish Education?*
Does you child read basic Hebrew?*

YesNo
If you answered YES to the above question please select*

WellFairPoor
Parent Information:
Mother's Name (or Guardian Name)*

First Name Last Name
Jewish/Hebrew Name?
Is the Mother...*

Jewish by birthJewish by conversion (universally accepted)Not Jewish
Occupation?
Cell Phone Number*

Area Code Phone Number
E-mail*
Father's Name (or Guardian Name)*

First Name Last Name
Jewish/Hebrew Name?
Is the Father...*

Jewish by birthJewish by Conversion (universally accepted)Not Jewish
Occupation?
Cell Phone Number*

Area Code Phone Number
E-mail*
Are there any other conversions in the family history?*
Medical Information:
Doctor's Name*

First Name Last Name
Medical Coverage:*

Insurance Company Policy Number
Are there any allergies or any other medical conditions? If yes please explain.*
Date of last tetanus shot?*

Month Day Year
Please list 2 Emergency Contacts:
#1 - Full Name*

First Name Last Name
Phone Number*

Area Code Phone Number
Relationship*
#2 - Full Name*

First Name Last Name
Phone Number*

Area Code Phone Number
Relationship*
Permission for emergency medical treatment:
As the parent(s) or legal guardian(s) of the child listed above, I/we authorize any adult acting on behalf of Chabad of Summerlin Hebrew School to secure medical 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 of Summerlin Hebrew School will make every effort to communicate with me prior to such treatment.

I/we hereby give permission for my child listed above to attend all field trips and outings organized by Chabad of Summerlin Hebrew School.
Typing you name here serves as a legal signature*
Date*

Month Day Year
TUITION AGREEMENT
• The tuition for Hebrew School is $700.00 per year per child (this includes a registration & book fee). There is a 10% discount off of the regular tuition for each additional child of the same family.

• Tuition payment must be submitted to the school office before any child will be permitted to attend classes.

You may choose from the following payment methods:

► PLAN A: You may pay the entire amount in full entitling you to a $75.00 discount off of the regular tuition.

► PLAN B: You may use your Visa or Master Card to pay the tuition. Your credit card will be billed $70.00 monthly September through June. To do so please include your credit card number and expiration date at the bottom of this page.

► PLAN C: You may pay the annual tuition on a monthly basis by submitting up front 10 checks of $70.00 each, dated September through June. All checks must be submitted before the first day of Hebrew School.

• Refunds for children withdrawing from school before the end of the school year will be granted provided that the school office is given 30 days written notice. Tuition refunds will not be granted to children withdrawing from school after April 1^st.

• To request a scholarship or to receive the sibling discount (additional family member) please click below to explain your needs.

• No child will be turned away due to lack of funds.

PAYMENT MUST BE MADE EVEN IF YOUR CHILD/REN MISSES A DAY OR MORE. THE PAYMENT AGREEMENT IS FOR THE SCHOOL YEAR AND NOT PER WEEK UNLESS OTHER ARRANGEMENTS ARE MADE IN ADVANCE.
Payment Options - Full Tuition = $700*

Plan A: Pay in full and receive a $75 discount. = $625 todayPlan B: 10 Monthly Credit Card Charges of $70 = $70 today and $700 totalPlan C: 10 Post Dated Checks (1 per month) due before first day of Hebrew School = $700 total
Scholarship Request & Family Discount (please explain)
Based on your previously selected plan, please select the amount you are paying today.

If you have chosen Plan A please selection $625.

If you have chosen Plan B please select $70.

If you have selected Plan C and will write up checks or have a scholarship that doesn't require payment please select $0 .
Amount Paying Today*

$625$70$0
I would like to donate to the Hebrew school Scholarship Fund to help others who can't afford

$18.00$50.00$75.00$100.00$180.00$500.00$1000.00$1800.00
Yes, I'd like to make this a monthly recurring payment.
I would like to sponsor security for one session of Hebrew School

$75

Payment*

Credit Card Paypal Zelle, Checks

Postal / Zip Code

Country

Total

$0.00
Should be Empty:

Student Information:

Parent Information:

Medical Information:

Please list 2 Emergency Contacts:

Permission for emergency medical treatment:

TUITION AGREEMENT