Student Information: Full Name* First Name Last Name Hebrew Name Date of Birth 1 - January2 - February3 - March4 - April5 - May6 - June7 - July8 - August9 - September10 - October11 - November12 - December Month12345678910111213141516171819202122232425262728293031 Day20202019201820172016201520142013201220112010 Year School* Grade Entering* Previous Jewish Education YesNo Where? Please select which track your child will be attending:* Grades K-6 Tuesdays 4:00-5:30pmBat Mitzvah Club! - Select Wednesdays Parent Information: Father's Name* First Name Last Name Father's Phone Number* Area Code Phone Number Father's E-mail* Is father Jewish? Yes, by birthYes, by conversion No Mother's Name* First Name Last Name Mother's Phone Number* Area Code Phone Number Mother's E-mail* Is mother Jewish? Yes, by birthYes, by conversion No Emergency Information: Emergency Contact 1* Phone Number* Area Code Phone Number Emergency Contact 2* Phone Number* Area Code Phone Number Doctor* Phone Number* Area Code Phone 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. Payment Information: Hebrew School Registration:* Includes Textbooks and Supplies Returning Student Discount: $1200Returning Student Sibling Discount: $1080Sibling Discount: $1350Sibling Discount 10 Monthly Installments $135/month (Sep-June)HS Tuition $1500HS Tuition 10 Monthly Installments $150/month (Sep-June) Check box below if you are making monthly Installments Yes, I'd like to make this a monthly recurring payment. Please consider an added donation to our scholarship fund Please select$120$180$360$540$1200$1800 Total $0.00 Yes, I'd like to donate the cost of processing this transaction by adding 3% Payment Credit Card We accept Visa, MasterCard, American Express, Discover Credit Card Number Security Code Name on Card1 - January2 - February3 - March4 - April5 - May6 - June7 - July8 - August9 - September10 - October11 - November12 - December Expiration Month2024202520262027202820292030203120322033 Expiration YearBilling Address Street Address City State / Province Postal / Zip CodePlease SelectUnited StatesAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanThe BahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChilePeople's Republic of ChinaRepublic of ChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCook IslandsCosta RicaCote d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonThe GambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern MarianaNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint BarthelemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSomalilandSouth AfricaSouth OssetiaSpainSri LankaSudanSurinameSvalbardSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTristan da CunhaTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamBritish Virgin IslandsUS Virgin IslandsWallis and FutunaWestern SaharaYemenZambiaZimbabweOther Country Authorization: Transport / Emergency Care as listed above Authorization: I hereby give permission for my child to be transported to and from field trips, and to participate in them in all RSF Hebrew School activities. I understand that during the course of RSF Hebrew School my child can be hurt. I accept the risk of possible injury and authorize any member of the Chabad RSF Hebrew School staff to render any necessary first aid. Furthermore, in an emergency case, I hereby authorize Devorah Raskin, Rabbi Levi Raskin or another staff member to have my child taken care of by a physcian or other medical person in any way the situation calls for. Transport / Emergency Care as listed above Authorization* I give permissionI don't give permission Initials Here:* Submit Should be Empty: This page uses TLS encryption to keep your data secure.