Registration

We are currently accepting application forms for the 2010-2011 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 at: 516-767-8672

Click Here to download a pdf and mail it in to our office: 
80 Shore Rd. | Port Washington | NY | 11050

Please note that one registration form per child is needed.

STUDENT INFORMATION
First Name			Last Name
Hebrew Name			D.O.B.	Month Jan. Feb. Mar. Apr. May Jun. Jul. Aug. Sept. Oct. Nov. Date 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31  Year 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007
School			Grade Entering	Grade Entering Kindergarten First Second Third Fourth Fifth Sixth Seventh
Hebrew Reading Proficiency	None    Somewhat    Well
Previous Jewish Education	Yes             No            If yes - where?

PARENT INFORMATION
Father's Name			Father's Cell
Jewish By:	Birth Conversion
Mother's Name			Mother's Cell
Jewish By:	Birth Conversion
Address			City, State, Zip
Home Phone			Email
Synagogue affiliated with:

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. 

  
As the parent(s) or legal guardian of the above child, I/we authorize any adult acting on behalf of Chabad of PW 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 of PW 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 of PW Hebrew School activities and that these pictures may be used for marketing purposes.

I Accept   

Name:     Initials: 

PAYMENT OPTIONS Full tuition: $695.00 (Members $345.00)
Yes, we are members of Chabad of Port Washington No, we are not members of Chabad of Port Washington
Please choose one of the following payment options:
1. Divide my payments into 2 charges of $347.50 ($172.50 for members)
2 postdated checks- Dated 9/1/10 and 1/1/11.          Due by the first day of School  2 credit card payments-Charged on 9/1/10 and 1/1/11           Due by the first day of school
2. Divide my payments into 4 charges of $173.75 ($86.25 for members)
4 postdated checks-Dated 9/1/10, 12/1/10, 2/1/11, 5/1/11.          Due by the first day of school.  4 credit card payments- Charged on 9/1/10, 12/1/10, 2/1/11, 5/1/11       Due by the first day of school
Credit Card Information:
Name on card			Card Type	Select American Express Visa Mastercard
Charge Amnt.			Card Number
Exp. Date	Month Jan Feb March April May June July Aug Sept Oct Nov Dec   Year 2009 2010 2011 2012 2013 2014 2015		CVV Code	3 digits on back of card

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