Registration - JewishJupiter.com

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Hebrew school takes place weekly on Monday afternoons
Elementary: 3:30-5:00pm or Middle School: 4:30-6:00pm

If you have any questions or concerns you'd like to discuss with us, feel free to call our director Sarah 561-222-4083 or [email protected]

Parent Information:

Mother's Name

First Name Last Name

Mother's E-mail

Mother's Cell

Area Code Phone Number

Father's Name

First Name Last Name

Father's E-mail

Father's Cell

Area Code Phone Number

Address

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

Phone Number

Area Code Phone Number

Student Profile:

Name*

First Name Last Name

Hebrew Name*

Age*

Birth Date*

Month Day Year

Time of Birth* In Judaism the day begins at nightfall, so in order to determine the exact date of your Jewish birthday we need to know what time of day you were born.

Hour Minutes

School*

Grade Entering*

Are there conversions in the family? If yes, please specify.

Emergency Information:

Emergency Contact 1

First Name Last Name

Phone Number

Area Code Phone Number

Emergency Contact 2

First Name Last Name

Phone Number

Area Code Phone Number

Doctor's Name

First Name Last Name

Doctor's Phone Number

Area Code Phone Number

Medical Insurance Company

Policy Number

Please specify any allergies or medical conditions we should be aware of Confidential

Registration and Sponsorship:
$150 registration fee will be applied.

Registration Fee*

$150

Hebrew School Fee*

1 payment by Credit Card $600 (form below)$150 paid now, 3 additional payments in September, December & March

Hebrew School Sponsor

$1,800

Scholarship Sponsor

one scholarship $600two scholarships $1200three scholarships $1800

We encourage our families to partner with Chabad of Jupiter by participating in the Partners Program, a monthly recurring donation in the desired amount.

I would like to be a partner. Please charge my credit card each month.

$

Registration and Sponsorship Payment:

Total

$0.00

Payment*

Credit Card

We accept Visa, MasterCard, American Express, Discover
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

Agreement:

In case of an emergency, as the parent(s) or legal guardian of the above child, I/we authorize any adult acting on behalf of Chabad Jewish Center of Jupiter 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 Jewish Center of Jupiter 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 activities, join in trips on and beyond school properties and allow my child to be photographed while participating in Chabad Jewish Center of Jupiter activities and that these pictures may be used for marketing purposes.

I accept

I grant my child permission to join Chabad Jewish Center of Jupiter on trips and transportation to trips.

Name

First Name Last Name

Date

Month Day Year

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