Registration - Chabad of La Jolla

Student Information:
Full Name*
First Name Last Name
Hebrew Name
Date of Birth

Month Day Year
School*
Grade Entering*
Previous Jewish Education
Where?
Please select which track your child will be attending:*

Grades K-2 Tuesdays 3:30-4:30pmGrades 3-6 WendsdaysBar Mitzvah Lessons - Thursday EveningsBat Mitzvah Club! - Select Sundays
Parent Information:
Father's Name*
First Name Last Name
Father's Phone Number*

Area Code Phone Number
Father's E-mail*
Is father Jewish?
Mother's Name*
First Name Last Name
Mother's Phone Number*

Area Code Phone Number
Mother's E-mail*
Is mother Jewish?
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

Hebrew School Tuition: $1200Hebrew School Sibling Discount: $1100Hebrew School Tuition 10 Installments $133/month
Please consider an added donation to our scholarship fund
Total

$0.00
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Yes, I'd like to make this a monthly recurring payment.

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Name on Card
Expiration Month	Expiration Year

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