Student Profile
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First Name |
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Last Name |
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Hebrew Name |
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DOB |
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School |
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Grade Entering |
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Hebrew Reading Proficiency |
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Previous Jewish Education |
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Where? |
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Parent Information
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Father's Name |
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Phone |
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Mother's Name |
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Phone |
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Address |
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City |
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State |
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Zip |
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Email Address |
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Emergency Information
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Emergency Contact 1 |
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Phone |
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Emergency Contact 2 |
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Phone |
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Doctor |
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Address |
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Phone |
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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. |
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FOR IN PERSON STUDENTS:
Due to Covid-19: The morning of in person classes, each Parent is responsible to submit an online Health Screening Questionaire, as well as inform us if any family members have been exposed to or have any symptoms associated with COVID-19, such as fever, difficulty breathing, coughing or loss of smell throughout the year.
I will notify CHS of any Covid exposure/symptoms.
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Payment Information
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Bar Mitzvah Lessons:
Full Payment $1800 | Monthly Payment $180
Hebrew School Student Discount:
Full Payment $1500 | Monthly Payment $150 |
Selection: |
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Please consider an added donation to our scholarship fund
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Amount to be charged today: |
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Credit Card Number |
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CVV |
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Expiration Date (MM/YYYY) |
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As always, no child will be turned away due to lack of funds! SCHOLARSHIP AVAILABLE
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Authorization
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Transport / Emergency Care as listed above Authorization |
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Media Authorization |
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