Register

Parents Information
If any question is not applicable, please write N/A
Father's Name*

First Name Last Name
Father's Cell*

Area Code Phone Number
Father's Email*
Father's Occupation*
Father's Hebrew Name
Mother's Name*

First Name Last Name
Mother's Cell*

Area Code Phone Number
Mother's Email*
Mother's Occupation*
Mother's Hebrew Name
Do Parents Live Together?*

YesNo

Address*

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

Father's Address*

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

Mother's Address*

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

Are there any conversions or adoptions in the family?
Mother*

YesNo
Maternal Grandmother*

YesNo
Maternal Grandfather*

YesNo
Father*

YesNo
Paternal Grandmother*

YesNo
Paternal Grandfather*

YesNo
Please provide further details about conversions and/or adoptions in the family.
Are the biological parents of the child/ren Jewish?
Father*

YesNo
Mother*

YesNo
Emergency Contact
Name*

First Name Last Name
Cell Phone*

Area Code Phone Number
Relationship*
Student Information
How many children are you enrolling?*

1 Student2 Students3 Students
Child 1: Full Name*

First Name Last Name
Hebrew Name
Birth Date*

Month Day Year
Time of Birth

Hour Minutes
Age as of 9/11/2023*
Grade as of 9/11/2023*
Previous Jewish Education*
Please select the program this child will be joining*

Hebrew School ProgramThe Kulanu Circle - Inclusion Program
To assist us in providing the best possible experience for your child, please email their IEP to [email protected].
IEP*

I confirm I have emailed my child's IEP to [email protected]
We want to provide the best possible experience for your child. Please describe your child's diagnosis:*
Please list any allergies, food sensitivities, or applicable medical concerns:*
What does your child enjoy doing the most?*
What makes your child upset? What are his/her triggers?*
Please provide as much information as possible regarding aggressive behaviors so our BCBA's can target decreasing these behaviors.*
What strategies do you use to calm your child down?*
What type of consequence/reward system do you use with your child?*
Please describe your child's academic level/ability.*
Can your child read?*
Can your child write?*
Describe your child's classroom setting. *
How does your child learn best?*
Is your child toilet trained?*

YesNo
Does your child receive ABA therapy?*

YesNo
Does your child have any medical conditions, allergies, special needs, or behavioral issues?* Or is there anything else we should know to help us best accommodate your child?

YesNo
Additional notable Information* Please let us know about any medical conditions, allergies, special needs, behavioral issues, or anything else that will help us accommodate your child
Child 2: Full Name*

First Name Last Name
Hebrew Name
Birth Date*

Month Day Year
Age as of 9/11/2023*
Grade as of 9/11/2322*
Previous Jewish Education*
Please select the program this child will be joining*

Hebrew School ProgramThe Kulanu Circle - Inclusion Program
To assist us in providing the best possible experience for your child, please email their IEP to [email protected].
IEP*

I confirm I have emailed my child's IEP to [email protected]
We want to provide the best possible experience for your child. Please describe your child's diagnosis:*
Please list any allergies, food sensitivities, or applicable medical concerns:*
What does your child enjoy doing the most?*
What makes your child upset? What are his/her triggers?*
Please provide as much information as possible regarding aggressive behaviors so our BCBA's can target decreasing these behaviors.*
What strategies do you use to calm your child down?*
What type of consequence/reward system do you use with your child?*
Please describe your child's academic level/ability.*
Can your child read?*
Can your child write?*
Describe your child's classroom setting. *
How does your child learn best? *
Is your child toilet trained?*

YesNo
Does your child receive ABA therapy?*

YesNo
Does your child have any medical conditions, allergies, special needs, or behavioral issues?* Or is there anything else we should know to help us best accommodate your child?

YesNo
Additional notable Information* Please let us know about any medical conditions, allergies, special needs, behavioral issues, or anything else that will help us accommodate your child
Child 3: Full Name*

First Name Last Name
Hebrew Name
Birth Date*

Month Day Year
Age as of 9/11/23*
Grade as of 9/11/23*
Previous Jewish Education*
Please select the program this child will be joining*

Hebrew School ProgramThe Kulanu Circle - Inclusion Program
To assist us in providing the best possible experience for your child, please email their IEP to [email protected].
IEP*

I confirm I have emailed my child's IEP to [email protected]
We want to provide the best possible experience for your child. Please describe your child's diagnosis:*
Please list any allergies, food sensitivities, or applicable medical concerns:*
What does your child enjoy doing the most?*
What makes your child upset? What are his/her triggers?*
What strategies do you use to calm your child down?*
Please provide as much information as possible regarding aggressive behaviors so our BCBA's can target decreasing these behaviors.*
What type of consequence/reward system do you use with your child?*
Please describe your child's academic level/ability.*
Can your child read?*
Can your child write?*
Describe your child's classroom setting. *
How does your child learn best? *
Is your child toilet trained?*

YesNo
Does your child receive ABA therapy?*

YesNo
Does your child have any medical conditions, allergies, special needs, or behavioral issues?* Or is there anything else we should know to help us best accommodate your child?

YesNo
Additional notable Information* Please let us know about any medical conditions, allergies, special needs, behavioral issues, or anything else that will help us accommodate your child
Waiver*

By checking here, I hereby permit my child/ren to participate in all Hebrew School activities and trips, on and beyond the hebrew school campus.By checking here, I hereby authorize the Hebrew School, its staff and/or representatives to have my child given proper medical attention in the case of an emergency.By checking here, I authorize Chabad Hebrew School to use photographs of my child/ren during activities and trips in Hebrew School newsletters and promotional material.
If your family is new to the Hebrew School and you were referred by another Hebrew School family, please write their name:
Payment
Due Now:

Registration fee: $100 per child.

Book fee: $30 per child.
Total Due Now

$130.00
Due later:

We will calculate your tuition balance based on the fees and discounts listed here.

We offer three payment plans:

1. Pay balance in one installment on August 1st, 2023.

2. Pay balance in two installments on August 1st, 2023 & January 1st 2024.

3. Pay balance in 10 monthly installments starting on August 1st, 2023 & finishing on May 1st 2024.
Payment Plan*

1 Installment2 Installments10 Monthly Installments
Authorization*

I authorize Chabad Hebrew School to automatically charge my card on file based on my selected payment plan

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

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Educate Your Child... Educate a Generation

Parents Information

Emergency Contact

Student Information

Payment