New student registration Family info Father's name Father's email Father's Phone Number Is the father Jewish? YesNo Mother's name Mother's email Mother's Phone Number Is the Mother Jewish? YesNo Child's Primary Address City State ALAKAZARCACOCTDEFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMONENVNHNJNMNYNCNDOHOKORPARHSCSDTNTXUTVTVAWAWVWIWY Zip Code Marital Status? SingleMarriedDivorcedOther Any conversions in the family? YesNo If so, please explain. Child info How many children are you registering? 1234567 Child #1's legal name Child #1's Hebrew name Child #1's Birthday Please indicate time of birth as Before SunsetAfter SunsetUnknown School child #1 is attending in the fall: Grade child #1 is entering in the fall Pre-KKindergarden1st2nd3rd4th5th6th7th8th9th Is Child #1 adopted? YesNo Please write all medications Child #1 takes Child #1's allergies to food or meds Does Child #1 need an epi-pen? YesNo Does your child have any medical, developmental or behaviorial issue that we should know about? YesNo If so, please explain Can your child read basic Hebrew yet? YesNo Child #2's legal name Child #2's Hebrew name Child #2's Birthday Please indicate time of birth as Before SunsetAfter SunsetUnknown School child #2 is attending in the fall: Grade child #2 is entering in the fall Pre-KKindergarden1st2nd3rd4th5th6th7th8th9th Is Child #2 adopted? YesNo Please write all medications Child #1 takes Child #2's allergies to food or meds Does Child #2 need an epi-pen? YesNo Does your child have any medical, developmental or behaviorial issue that we should know about? YesNo If so, please explain Can your child read basic Hebrew yet? YesNo Child #3's legal name Child #3's Hebrew name Child #3's Birthday Please indicate time of birth as Before SunsetAfter SunsetUnknown School child #3 is attending in the fall: Grade child #3 is entering in the fall Pre-KKindergarden1st2nd3rd4th5th6th7th8th9th Is Child #3 adopted? YesNo Please write all medications Child #3 takes Child #3's allergies to food or meds Does Child #3 need an epi-pen? YesNo Does your child have any medical, developmental or behaviorial issue that we should know about? YesNo If so, please explain Can your child read basic Hebrew yet? YesNo Child #4's legal name Child #4's Hebrew name Child #4's Birthday Please indicate time of birth as Before SunsetAfter SunsetUnknown School child #4 is attending in the fall: Grade child #4 is entering in the fall Pre-KKindergarden1st2nd3rd4th5th6th7th8th9th Is Child #4 adopted? YesNo Please write all medications Child #1 takes Child #4's allergies to food or meds Does Child #4 need an epi-pen? YesNo Does your child have any medical, developmental or behaviorial issue that we should know about? YesNo If so, please explain Can your child read basic Hebrew yet? YesNo Child #5's legal name Child #5's Hebrew name Child #5's Birthday Please indicate time of birth as Before SunsetAfter SunsetUnknown School child #5 is attending in the fall: Grade child #5 is entering in the fall Pre-KKindergarden1st2nd3rd4th5th6th7th8th9th Is Child #5 adopted? YesNo Please write all medications Child #5 takes Child #5's allergies to food or meds Does Child #5 need an epi-pen? YesNo Does your child have any medical, developmental or behaviorial issue that we should know about? YesNo If so, please explain Can your child read basic Hebrew yet? YesNo Child #6's legal name Child #6's Hebrew name Child #6's Birthday Please indicate time of birth as Before SunsetAfter SunsetUnknown School child #6 is attending in the fall: Grade child #6 is entering in the fall Pre-KKindergarden1st2nd3rd4th5th6th7th8th9th Is Child #6 adopted? YesNo Please write all medications Child #1 takes Child #6's allergies to food or meds Does Child #6 need an epi-pen? YesNo Does your child have any medical, developmental or behaviorial issue that we should know about? YesNo If so, please explain Can your child read basic Hebrew yet? YesNo Child #7's legal name Child #7's Hebrew name Child #7's Birthday Please indicate time of birth as Before SunsetAfter SunsetUnknown School child #7 is attending in the fall: Grade child #7 is entering in the fall Pre-KKindergarden1st2nd3rd4th5th6th7th8th9th Is Child #7 adopted? YesNo Please write all medications Child #7 takes Child #7's allergies to food or meds Does Child #7 need an epi-pen? YesNo Does your child have any medical, developmental or behaviorial issue that we should know about? YesNo If so, please explain Can your child read basic Hebrew yet? YesNo List name(s) of those other than parents authorized to pick kid(s) from school Payment info Total tuition is $950 per child: $100 Deposit per child is due with registration. The deposit will be deducted from the total tuition. (Tuition includes security and book fee.) Payment options: Payment in full upon registration10 monthly payments From Aug 1, 2021 through May 1, 2022I have spoken with the office about an alternative payment option Credit Card Number Name on Card Expiration month 123456789101112 Expiration year 2122232425262728293031323334353637383940 Is the billing address the same as listed above? NoYes Please enter your Billing address Tuition Total Promo Code Total: $100 deposit + $850 tuition Total: $100 deposit + $800 tuition Total: $100 deposit + $750 tuition Total: $200 deposit + $1700 tuition Total: $200 deposit + $1600 tuition Total: $200 deposit + $1500 tuition Total: $300 deposit + $2550 tuition Total: $300 deposit + $2400 tuition Total: $300 deposit + $2250 tuition Total: $400 deposit + $3400 tuition Total: $400 deposit + $3200 tuition Total: $400 deposit + $3000 tuition Total: $500 deposit + $4250 tuition Total: $500 deposit + $4000 tuition Total: $500 deposit + $3750 tuition Total: $600 deposit + $5100 tuition Total: $600 deposit + $4800 tuition Total: $600 deposit + $4500 tuition Total: $700 deposit + $5950 tuition Total: $700 deposit + $5600 tuition Total: $700 deposit + $5250 tuition ~~~~ To enroll your child(ren) in Chabad of Boca Raton West Hebrew School all forms must be submitted with the required fees. Enrollment is considered to be for the entire school year. The school cannot issue refunds or credits for illness, holidays, family vacations, or early withdrawal. In the event that the school is closed due to or resulting from a weather emergency or other unforeseen circumstances, there will be no make-up days, refunds or credits for days that school is not in session. Upon processing a tuition payment, if sufficient funds are not available or the credit card is not approved, your account will be charged $25 for each transaction that could not be processed. Parent(s) acknowledge that Chabad Hebrew School serves children who are able to function successfully in a group setting. If, in the judgement 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. We give permission for the use of photographs of our child(ren) in print materials, on our website, social media and/or emails. Last names of children are never listed. We give permission for our name and telephone number(s) to be included in any class list that may be distributed. Medical Emergencies I hereby give permission, in the event of an emergency, for the Director, Acting Director, or the Teacher at Chabad Weltman Hebrew School to take whatever steps may be necessary for the medical care of my child. I understand that in order for Chabad Weltman Hebrew School to assume responsibility for my child, I, or the person(s) whom I have designated to drop off and pick up my child, must sign my child in at the time of arrival and out at the time of departure. I understand that unless there is a need for immediate action, the order of the steps taken will follow, but will not be limited to, the outline below: 1. The parent/guardian will be called. Note: If the parent/guardian is unavailable, the emergency contact person designated by the parent/guardian will be called. 2. Child's physician will be called. 3. If these efforts are unsuccessful the following steps will be taken (order may vary depending on the situation): a. Another physician will be called. b. The child will be taken to the nearest emergency room accompanied by a staff member. c. An ambulance will be called to take the child to the nearest emergency room accompanies by a staff member. In the event of an emergency, if I cannot be reached, I give consent for a Chabad staff member to transport my child to the nearest emergency facility, or to have my child transported by ambulance. I give consent to any emergency facility and physician to administer any necessary medical treatment to my child as the situation may warrant it. Emergency contact #1 name Emergency contact #1 number If parents cannot be reached and emergency medical advice is needed, permission is given to Chabad Hebrew School staff to phone my child's doctor. In case of a 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 of Boca Raton West and Hebrew School 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. Family doctor Doctor's phone number
