JDZ/Hebrew School Registration ____________________

1. Parents Information

Mother's Name

Address 

City                                        State        Zip
                
Home Phone Number           Office Phone Number
                   
Mobile Phone Number      Fax Number
                   
E-mail
 

 Please add to the Chabad of Mt. Olympus mailing list

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Father's Name
 
     
 fathers contact information is the same as above

Address


City                                        State        Zip
                
Home Phone Number           Office Phone Number
                  
Mobile Phone Number      Fax Number
                 
E-mail
 

 Please add to the Chabad of Mt. Olympus mailing list

2. Childs Information 
  
Name
 
Child's Hebrew Name                  Birthday                      Age
     
School                                                             Grade
   
Allergies or Medication
 
Any special medical or other information we should be aware of?

Has he/she ever received any Hebrew education?
YES at  year  last Hebrew grade 
           name of educational institute
NO

4. Emergency Contact Information
for emergency purposes, where the parents is not available, please provide us with an emergency contact such as a relative or friend who knows the child well

Name                                                Relation to child
 
Address 

City                                        State        Zip
                
Home Phone Number           Office Phone Number
                   
Mobile Phone Number      Fax Number
                   
E-mail

4. Payment Information

 I will be sending a check for the TOTAL amount of $
(please make checks payable to Chabad of Mt. Olympus)
  
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 Please charge my credit card the TOTAL amount of $

                                            -Please note: a 2.5% cc charge will be added

Credit Card Type       Credit Card Number   Exp:
   
Name on card
  
         
 Please notify me when my registration complete with payment is received.

All contributions are tax-deductible.

 I hereby register my child/ren in Chabad of Mt. Olympus Hebrew School and give permission for my child to participate in all school activities, including outings. I understand that the school does not assume responsibility for any injuries, and in case of emergency, necessary medical attention may be secured by the school.

 Please note: No form will be processed unless proper payment is issued at the time of registration.