Family Information
Family Name      
Address City
Zip Code Home Phone
Father's Name Hebrew name (if available)
Father's Email Father's Cell Phone
Mother's Name Hebrew name (if available)
Mother's Email Mother's Cell Phone
Marital Status of Parents Any conversions in the family?
Is the father Jewish? Is the mother Jewish?
Child Information
1. Child's Name

Hebrew Name
DOB Before or after sunset?
School Attending Grade Entering
Is the child adopted? List regular medications
Allergies to food or meds? Need for an Epi-pen?
Does your child read basic Hebrew?      
2. Child's Name Hebrew Name
DOB Before or after sunset?
School Attending Grade Entering
Is the child adopted? List regular medications
Allergies to food or meds?   Need for Epi-pen?  
3. Child's Name Hebrew Name
DOB Before or after sunset?
School Attending Grade Entering
Is the child adopted? List regular medications
Allergies to food or meds?  Need for Epi-pen?

4. Child's Name Hebrew Name
DOB Before or after Sunset
School Attending Grade Entering
Is the child adopted? List regular medications  
Allergies to food or med?
Need for Epi-pen?
Please name/age siblings who are not being enrolled in the Hebrew School for the year 2019-2020
Please list name(s) of those (other than parents) who are authorized to pick up from school                        
Tuition & Payment                     
$100 deposit, per child, is due with registration by credit card.  
The deposit will be deducted from the total tuition.  
Tuition includes security and book fee.
Member  $750 Tuition per child             Non Member  $850 Tuition per child 
                                                               Total Tuition for the year:   
Tuition may be paid in either  8 payments (September 1, 2019 thru April 1, 2020) or in full by September 1, 2019.
By registering your child(ren) you are agreeing to the tuition payment schedule indicated below
and your credit card will be charged accordingly.
If you would like to pay the monthly payments by check, please call the office at 487-2934
Card Holder Name Card Holder Address:
Credit Card Number Total to charge at Registration
Exp Date

Tuition Payment Schedule:
Indicate how tuition will be paid.
1 payments or 8

Enrollment Agreement
To enroll your child(ren) in Chabad of Boca Raton West Hebrew School all forms must be submitted with the required fees.  
Enrollment is considered to be for the entire school year.  The school cannot issue refunds or credits for illness, holidays, family vacations or early withdrawal.  In the event that the school is closed due to or resulting from a weather emergency or other unforeseen circumstances, there will be no make-up days, refunds or credits for days that school is not in session.
Upon processing a tuition payment, if sufficient funds are not available or the credit card is not approved, your account will be charged $25 for each transaction that could not be processed.
Parent(s) acknowledge that Chabad Hebrew School serves children who are able to function successfully in a group setting. If, in the judgment of the school's Director, the child is not able to function in a group setting, the parent may be asked to withdraw the child. In the event that the parent is requested to withdraw the child, the Director will work with the parent to identify possible alternative programs suitable for the child.

We give permission to use photographs of our child(ren) in print materials, on our website and/or emails.  Last names of children are never listed.  We give permission for our name and telephone number to be include in any class list that may be distributed. 

Medical and Developmental History
Does your child's (indicate which child) have any medical, developmental or behavioral issue that we should know about? Describe:
Medical Emergencies

I hereby give permission, in the event of an emergency, for the Director, Acting Director, or the Teacher at Chabad Weltman Hebrew School to take whatever steps may be necessary for the medical care of my child. I understand that in order for Chabad Weltman Hebrew School to assume responsibility for my child, I, or the person(s) whom I have designated to drop off and pick up my child, must sign my child in at the time of arrival and out at the time of departure.  I understand that unless there is a need for immediate action, the order of the steps taken will follow, but will not be limited to, the outline below:

1. The parent/guardian will be called.  Note: If the parent/guardian is unavailable, the emergency contact person designated by the parent/guardian will be called.

2. Child's physician will be called. 

3. If these efforts are unsuccessful the following steps will be taken (order may vary depending on the situation):

    a. Another physician will be called.

    b. The child will be taken to the nearest emergency room accompanied by a staff member.

    c.  An ambulance will be called to take the child to the nearest emergency room accompanies by a staff                      member.

In the event of an emergency, if I cannot be reached, I give consent for a Chabad staff member to transport my child to the nearest emergency facility, or to have my child transported by ambulance.  I give consent to any emergency facility and physician to administer any necessary medical treatment to  my child as the situation may warrant it.


A. In case of emergency, when neither parent can be reached, give names of two people who will take responsibility for your child:
Emergency Contact 1   Emergency Contact 2  
Name Name
Home Phone Home Phone
Cell Phone Cell Phone
Address Address
City City
Relationship to Student Relationship to Student
B. If parents cannot be reached and emergency medical advice is needed, permission is given to the Hebrew School staff to phone my child's doctor:
Doctor Phone
Address City
Hospital Affiliation    
C. In case of medical emergency requiring immediate emergency care, I authorize the paramedics to take my child to the nearest hospital if necessary. It is understood that I will hold Chabad of Boca Raton West and Hebrew School harmless for the nature and outcome of any emergency medical treatment. It is also understood that I leave the decision of what constitutes an emergency to the sole direction of the staff.
By submitting this form, and signing below below, parents accept the terms outlined above and agree to the charges on the credit card for the deposit and tuition.  Please sign (type) and date.
Mother's name typed in Date
Father's name typed in Date