We are currently accepting application forms for the 2018-2019 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. We look forward to a wonderful year of learning and growth. Student 1 Profile Student 2 Profile First Name First Name Last Name Last Name Hebrew Name Hebrew Name Age Age DOB Month Jan. Feb. Mar. Apr. May Jun. Jul. Aug. Sept. Oct. Nov. Dec. 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 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 DOB Month Jan. Feb. Mar. Apr. May Jun. Jul. Aug. Sept. Oct. Nov. Dec. 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 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 Time of Birth In Judaism the day begins at nightfall, so to determine the exact date of the Jewish birthday we need to know the time of day. Time of Birth In Judaism the day begins at nightfall, so to determine the exact date of the Jewish birthday we need to know the time of day. School School Grade Entering Select Kindergarten First Second Third Fourth Fifth Sixth Seventh Grade Entering Select Kindergarten First Second Third Fourth Fifth Sixth Seventh Hebrew Reading Proficiency None Somewhat Well Hebrew Reading Proficiency None Somewhat Well Previous Jewish Education Yes No Previous Jewish Education Yes No Where? Where? Does your child have any learning disabilities? Please specify This information will help us better cater to the needs of your child. Does your child have any learning disabilities? Please specify This information will help us better cater to the needs of your child. Family Information My child is a Select Kohen Levi Yisroel Not sure Are the natural father and mother of the child Jewish? Yes No If no, please explain. Have there been any conversions or adoptions in the family? Yes No If yes, please explain. Parent Information Father's Name Father's Cell Mother's Name Mother's Cell Home Phone Address City Zip Email* Synagogue Affiliation To enhance our curriculum we have school events and programs. Can you assist in event planning? Yes No Emergency Information Emergency Contact 1 Phone Relationship Emergency Contact 2 Phone Relationship Family Physician Phone 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. Tuition Agreement Tuition for the 2016-2017 school year is $600 per child (snacks and drinks included) Installments: Payment in Full upon submission Quarterly Installments Payment Information Payment Method Credit Card Check Checks can be mailed to Chabad of Park City • P.O. Box 681818 • Park City, UT 84068 Card Type Card Number Expiration CVV Additional Comments (optional): Terms of Agreement I agree that in the event of an emergency, Chabad Hebrew School has my permission to arrange for any necessary first-aid or care by a licensed physician/first-aid worker. Chabad Hebrew School has my permission to use my child's photo in its publicity materials. I have completed the Enrollment Form and agree to pay any balance according to the terms of agreement outlined above. Initials: We look forward to a wonderful year of learning and growth! This page uses 128 bit SSL encryption to keep your data secure.