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Hebrew School Registration

HEBREW SCHOOL REGISTRATION FORM
We are currently accepting application forms for the 2017-2018 school year. Please fill out ALL fields of this form. If you have any questions or concerns you'd like to discuss with us, please contact us.
Confirmation of acceptance will be acknowledged only after this registration form is reviewed and an acceptance letter is received.
Student Information
Student 1 Name*
First NameLast Name
Student 1 Hebrew Name
Student 1: Birth Date*
MonthDayYear
Student 1: Time of birth
Day timeNight time
Student 1: I can read Hebrew
None at allSomewhatWell
Student 1: Previous Jewish Education
YesNo
Please explain
Student 2 Name
First NameLast Name
Student 2 Hebrew Name
Student 2:Birth Date
MonthDayYear
Student 2: Time of birth
Day timeNight time
Student 2: I can read Hebrew
None at allSomewhatWell
Student 2: Previous Jewish Education
YesNo
Student #3 Name
First NameLast Name
Student 3 Birth Date
MonthDayYear
Student 3: Time of birth
Day timeNight time
Student 3: I can read Hebrew
None at allSomewhatWell
Student 3: Previous Jewish Education
YesNo
Parent Information
Parents
DadMom

Address

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

Home Phone Number
Area CodePhone Number
Dad Mobile Number
Area CodePhone Number
Dad E-mail
Mom Phone Number
Area CodePhone Number
Mom E-mail
I would like to receive news and updates by email
Family Information
Are there any conversion in the family?*
NoYes
Please explain
Members: please select how many children. 10% off additional children.
Please click here to become a member and join the Chabad of Pembroke Pines family.
Choose base on amount of children
$500$950$1400
Non-Members: please select how many children. 10% off additional children.
Choose base on amount of children
$600$1140$1680
Total
$0.00

Payment

Credit Card Bring/Mail a check

Postal / Zip Code

Country

* Feel free to discuss a payment plan with us. We can accomodate up to a 12 month payment plan.
** A 3% surcharge will be added to all credit card payments.
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