JLI Teens Form 5770

Filling out form does not mean acceptance, applicants are accepted based on first come first served basis, based on limited space available.    

Student Profile
 
Name
Last
Hebrew Name
DOB            
School
Grade Entering

Parent Information
 
Address
City/Zip
Phone
Email Address
Father's Name
Father's Cell
Mother's Name
Mother's Cell

Emergency Information
 
Emergency Contact 1
Phone
Emergency Contact 2
Phone
Doctor's Name
Doctor's Phone Number

CONFIDENTIAL: Does your child 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, I/we authorize any adult acting on behalf of Chabad 5 Towns  to hospitalize or secure treatment for my child, I further agree to pay all charges for that care and/or treatment. It is understood that if time and circumstances reasonably permit, Chabad 5 Towns personnel will try, but are not required, to communicate with me prior to such treatment. I hereby give permission for my child to participate in all school activities, join in class and school trips on and beyond school properties and allow my child to be photographed while participating in Chabad Hebrew School activities and that these pictures may be used for marketing purposes.

I Accept  

Should you wish to pay online 

Name:    
Initials: 

For your convenience, you can now pay for Hebrew School online.

This page uses a secure connection and your information will not be shared with anyone.  

Amount: $
Card Number
Last Name
City
Zip
Card Type
Exp. Date  
CW#