Registration 2024/2025

Please fill out this form and submit it together with your tuition, registration and book fees.

General Information:

Child's Full Name*

First Name Last Name

Child's Hebrew Name: *

Child's Preferred Name:*

Birth Date:*

Month Day Year

Hebrew Birth Date:*

Child's E-mail:

Parent E-mail:

Home Phone Number:

Area Code Phone Number

Address*

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

Religious & Educational History:

Does your child read basic Hebrew?*

NoneSomewhatWell

Does your child have any difficulty with his general studies?

Is the child's mother Jewish? *

Yes (if adopted/converted, please specify below)No

Is the child's father Jewish?*

Yes (if adopted/converted, please specify below)No

Are there any adoptions in your family (children, parents or grandparents)?

Have you or your spouse, parents, grandparents or children ever converted to Judaism?

Second Child's Full Name

First Name Last Name

Second Child's Hebrew Name:

Second Child's Preferred Name:

Second Child Birth Date:

Month Day Year

Second Child Hebrew Birth Date:

Second Child's E-mail

Religious & Educational History:

Does your child read basic Hebrew?

NoneSomewhatWell

Does your child have any difficulty with his general studies?

Third Child's Full Name

First Name Last Name

Third Child's Hebrew Name:

Third Child's Preferred Name:

Third Child's Birth Date:

Month Day Year

Third Child Hebrew Birth Date:

Third Child's E-mail

Religious & Educational History:

Does your child read basic Hebrew?

NoneSomewhatWell

Does your child have any difficulty with his general studies?

Fourth Child's Full Name

First Name Last Name

Fourth Child's Hebrew Name:

Fourth Child's Preferred Name:

Fourth Child's Birth Date:

Month Day Year

Fourth Child Hebrew Birth Date:

Fourth Child's E-mail

Religious & Educational History:

Does your child read basic Hebrew?

NoneSomewhatWell

Does your child have any difficulty with his general studies?

Contact Information:

Father's Name: *

Father's Hebrew Name:*

Work Phone Number:*

Area Code Phone Number

Other Phone Number:

Area Code Phone Number

Occupation:*

Company Name:*

Work Address:*

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

Mother's Name: *

Mother's Hebrew Name:*

Work Phone Number:*

Area Code Phone Number

Other Phone Number:

Area Code Phone Number

Occupation:*

Company Name:*

Work Address:*

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

Emergency Contact Person:(other than parent/guardian)

Full Name*

First Name Last Name

Relationship to child: *

Daytime Phone Number:*

Area Code Phone Number

Address*

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

Authorized Persons To Pick Up Your Child: (other than parents/guardians)

Full Name #1:*

First Name Last Name

Daytime Phone Number:*

Area Code Phone Number

Evening Phone Number:*

Area Code Phone Number

Address*

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

Full Name #2:*

First Name Last Name

Daytime Phone Number:*

Area Code Phone Number

Evening Phone Number:*

Area Code Phone Number

Address*

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

Sing-a- long Siddur (ages 4-6) $30

My First Siddur (ages 7-13) - $35

Tzitzit $15

CHS Kippah $15

I am registering my child for:

Track One in person HSTrack Two In Home HS

Payment Options: *

Payment in Full ($560 Tuition, $100 book & registration fee, $55 security fee)Three Equal PaymentsPayment in Full - 2 ChildrenThree Equal Payments - 2 ChildrenPayment in Full - 3 ChildrenThree Equal Payments - 3 ChildrenPayment in Full - 4 ChildrenThree Equal Payments - 4 Children

I do hereby state that I will pay my child's Hebrew School tuition to Chabad of Bradenton in three equal payments of $238.33. The first payment will be paid with registration, and each payment following will be paid on or by December 2024 and end by March 2025. Credit Card information or postdated checks must be presented with registration.

Total

$0.00

Payment

Credit Card Check Payment

Postal / Zip Code

Country

Signature:*

Date:*

Month Day Year

Medical Information:

Name of Child's Physician:*

Physician's Phone Number:*

Area Code Phone Number

Physician's Office Address:*

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

Insurance Company Covering the Child*

Policy Number:*

Expiration Date:*

Month Day Year

Please list below any psychological or medical conditions, medications currently being taken, dietary requirements, allergies(include allergies to medications), etc. pertaining to your child.

*

I hereby give permission, in the event of an emergency, for the Director, the Acting Director, or the Teacher at Chabad of Bradenton to take whatever steps maybe necessary for the medical care of my child. I understand that in order for Chabad of Bradenton 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:I give consent to any emergency facility and physician to administer any necessary medical treatment to my child as the situation may warrant it.

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 accompanied 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.

Parent/Guardian's Signature: *

Date:*

Month Day Year

I give consent for my child(ren)’s pictures to be used in all Chabad marketing materials. No names will be used.

YesNo

First Child

Second Child

Third Child

Fourth Child

Books / Judaic Supplies

Method of Payment:

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