Registration Form - ChabadMequon.org

Please fill out this form as registration for the Peltz Hebrew School.
Student Information
Full Name
First NameLast Name
Hebrew Name
Date of Birth
MonthDayYear
Age
Gender:
MaleFemale
Does your child read basic Hebrew?
NoneSomewhatWell
Does your child have previous Jewish Education?
YesNo
If yes, please describe
School attending:
Grade entering:
Synagogue affiliated with:
Were there any conversions or adoptions in your family?
YesNo
If yes, please describe
Any considerations, such as learning disorder or difficulty, the school should be aware of? (Confidential)
Parent Information
Father's Name
Home Phone
Area CodePhone Number
Work Phone
Area CodePhone Number
Cell Phone
Area CodePhone Number
E-mail
Occupation

Address

Address (if different than above)

Emergency Contact Information
Please list two contacts to be used in case of emergencies (other than your home and business numbers).
Emergency Contact 1 (other than parent)
Relationship to child

Home Address

Home Address

Home Phone
Area CodePhone Number
Work/Cell/Pager
Area CodePhone Number
I heard about the Peltz Hebrew School from:
Classes Schedule:
Sunday morning IN PERSON: 10:00 AM - 12:00 PM
Tuition is $400.00 per child, with discounts for multiple children.
Members of the congregation are not charged, except for a book fee of $40.
Should be Empty:

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Emergency Contact Information