Register Online - Chabad of Northeast Portland

We are currently accepting application for the 2016-2017 school year.

Please fill out ALL fields of this form and note that one registration form PER CHILD is needed.

please enter n/a if necessary.

We look forward to a wonderful year of learning and growth!

Student Information

First Name*

Last Name*

Hebrew Name*

Birth Date*

MonthDayYear

School*

Grade Entering*

Hebrew Reading Proficiency*

nonesomewhatwell

Previous Jewish Education*

yesno

Where?*

Name of Synagogue Affiliated With*

Parent Information

Address*

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

Phone Number*

- Area CodePhone Number

E-mail*

Father's Name*

Father's Mobile*

Father's Occupation*

Is Father Jewish?*

yesno

Mother's Name*

Mother's Mobile*

Mother's Occupation*

Is Mother Jewish?*

yesno

Emergency Information

Emergency Contact 1*

Relationship to Student*

Phone Number*

- Area CodePhone Number

Emergency Contact 2*

Relationship to Student*

Phone Number*

- Area CodePhone Number

Doctor's Name*

Doctor's Phone Number*

- Area CodePhone Number

CONFIDENTIAL: Does your child have any allergies or other medical condition we should be aware of? If yes, please describe them and indicate special precautions or care needed.

Authorization

As the parent(s) or legal guardian of the above child, I/we authorize any adult acting on behalf of Chabad Hebrew School to hospitalize or secure treatment for my child, I further agree to pay all charges for that care and/or treatment. It is understood that if time and circumstances reasonably permit, Chabad Hebrew School personnel will try, but are not required, to communicate with me prior to such treatment. I hereby give permission for my child to participate in all school activities, join in class and school trips on and beyond school properties and allow my child to be photographed while participating in Chabad Hebrew School activities and that these pictures may be used for marketing purposes.

I accept

Name*

Initials*

Date*

/Month /DayYear

Tuition Payment

Tuition

$550 (includes $50 registration fee required at time of registration to reserve your spot)

Register before July 1st and save 10% with our early registration discount.

Payment Options*

Pay in full, today. ($550)Pay in full on or before 9/1/2016 ($50 today and $500 due by 9/1/2016)Pay in two installments on 9/1/2016 and 1/1/2017 ($50 today and $250 on each payment day)Pay in 9 equal monthly payments, beginning 9/1/2016 ending 5/1/2016 ($50 today and 9 monthly payments of $55.55)

Total Due Today

$550.00 USD

Payment*

Credit Card Check

Postal / Zip Code

Country

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For any questions please email: [email protected]