Student #1 Profile
 
First Name
Last Name
Hebrew Name
Date of Birth
School Attending
Grade (Entering)
Hebrew Reading Proficiency None Somewhat Well
Previous Jewish Education Yes No
Where?
Is the natural mother of the child Jewish? Yes No
Have there been any conversions or adoptions in the family? If Yes, please explain.

 

Student #2 Profile
 
First Name
Last Name
Hebrew Name
Date of Birth
School Attending
Grade (Entering)
Hebrew Reading Proficiency None Somewhat Well
Previous Jewish Education Yes No
Where?
Is the natural mother of the child Jewish? Yes No
Have there been any conversions or adoptions in the family? If Yes, please explain.

 

Emergency Information
 
Emergency Contact 1
Phone
Emergency Contact 2
Phone

CONFIDENTIAL: Do(es) your child(ren) have any allergies or other medical condition we should be aware of? If yes, please describe them and indicate special precautions or care needed.


As the parent(s) or legal guardian of the above child(ren), I/we authorize any adult acting on behalf of Chabad to hospitalize or secure treatment for my child(ren), I further agree to pay all charges for that care and/or treatment. It is understood that if time and circumstances reasonably permit, Chabad personnel will try, but are not required, to communicate with me prior to such treatment. I hereby give permission for my child(ren) to participate in all C-Kidsl activities, join in class and school trips on and beyond school properties and allow my child to be photographed while participating in C-Kids activities and that these pictures may be used for marketing purposes.

I Accept -  Type Name:

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

Payment Information

Tuition: $600 annually per child. If you need scholarship assistance, please don't hesitate to contact Rabbi Backman at: [email protected] or by calling: 818-240-2750.

I would like to pay the C-Kids tuition by:
Check*
Credit Card payment in full
Charge my card in 10 monthly installments, beginning on September 15
Bill Me

Amount to be charged today  

Credit Card #       Expiration: 
Name on Card:   CCV:          


*Checks should be mailed to: Chabad Jewish Center, 1146 N. Central Avenue Box #135 • Glendale, CA 91202