Registration - Chabad of Great Neck

Child 1

Full Name*

First NameLast Name

Hebew Name*

Birth Date*

MonthDayYear

Age*

School Entering*

Grade Entering*

Child 2

Full Name

First NameLast Name

Hebew Name

Birth Date

MonthDayYear

Age

School Entering

Grade Entering

Parents Information

Home Number*

Area CodePhone Number

Address*

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Mother's Information

*

Mother's Full Name
Mother's Email
Mother's Cell Number	Mother's Work Number
Mother's Hebrew Name	Country

Additional Phone Number

Business Name

Father's Information

Father's Full Name
Father's Email
Father's Cell Number	Father's Work Number
Father's Hebrew Name	Country

Additional Phone Number

Business Name

Emergency Contact

Contact 1*

Name
Address
Cell Number	Home Number
Relationship	Country

Contact 2

Name
Address
Cell Number	Home Number
Relationship	Country

To enhance our curriculum we have school events and programs.

Would you be willing to assist in even planning?

YesNo

Would you like to be a class mother?

YesNo

I hereby permit my child to participate in all activities, join in class and school trips on and beyond school properties. In case of an emergency, I herby authorize the school to have my child taken care of by a physician in any way that the situation may call for.

Signature of Parent/Guardian: (Please enter your email address)*

Date*

MonthDayYear

Payment Options

PRICE:

Sunday: $1050 (Early Bird: $995 before July 26) - ($945 returning students).
Monday & Wednesday: $1300 (Early Bird: $1250 before July 26) - ($1195 returning students).
Sunday, Monday & Wednesday: $1600.
Bar & Bat Mitzvah (6th and 7th Grade - Sundays) $1200 - (1150 for returning student).

Sunday: $995

Returning Students Sunday: $945

Monday & Wednesday: $1250

Returning Students Monday & Wednesday: $1195

Sunday, Monday & Wednesday: $1600

Bar & Bat Mitzvah: $1200

Returning Students Bar & Bat Mitzvah: $1150

Amount to charge

$0.00

Terms and Conditions*

I, the undersigned agree, understand and authorize the amount shown above to be charged to my credit card for the items shown on the referenced order. I understand these charges will appear on my credit card statement under my name and I accept full financial responsibility for payment of this order.I agree payments are non-refundable and services / merchandise have been rendered / delivered to my satisfaction.

By entering your email you are accepting the terms above*

Payment*

Credit Card

Credit Card Type
Credit Card Number	Security Code
Name on Card
Expiration Month	Expiration Year

Billing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

I would like to receive news and updates by email