Register Online

We are currently accepting application forms for the 2015-2016 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.

If you would prefer to fill out this paper and mail it into our office, you print a PDF Printer Friendly Form.

Please submit a separate form for each child.

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

Student Profile
First Name
Last Name
Hebrew Name
Email Address
Gender
DOB
School
Grade Entering
Hebrew Reading Proficiency None Somewhat Well
Hebrew Language
Proficiency 		None Somewhat Well
Previous Jewish Education Yes No
Where?
Learning Difficulties Yes No
If yes, please describe:
Parent Information
Father's Information
First Name
Hebrew Name
Work Phone #
Cell Phone #
Email Address
Mother's Information
First Name
Hebrew Name
Work Phone #
Cell Phone #
Email Address
Family Information
Last Name
Address
Postal Code
Home Phone #
Fax #
Family History
Is Child's Father Jewish? Yes No
Is Child's Mother Jewish? Yes No
Emergency / Medical Information
Emergency Information

In case of illness or injury of a child at school, every effort will be made to contact the parent or guardian. If parent can not be reached please contact:
Emergency Contact 1
Name
Phone
Cell Phone
Relationship
Emergency Contact 2
Name
Phone
Cell Phone
Relationship
Medical Information
Family physician Name
Phone
Does your child have any allergies or other medical condition we should be aware of? Yes No
If yes, please describe them and indicate special precautions or care needed.
Is your child up to date with vaccinations? Yes No
Medical Release
I hereby consent to the administration of Chabad Park City Hebrew School to take whatever medical measures they deem necessary for my child in the event of a medical emergency.

I Agree
Payment/Tuition Information
Tuition Information
Price $600 Per School Year
(Snacks & Drinks Included)


Dates & Times Tuesdays 3:45 PM - 4:45 PM
Payment Information
Total Amount $600

Payment Plan
Payment Method
Card Type
Card #
Expiaration Date

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