Printed from ChabadPotomac.com
OF POTOMAC

Register - CTeen Jr. - Hebrew School

Register - CTeen Jr. - Hebrew School

Register Online

Please fill out ALL fields of this form. If you have any questions or concerns you'd like to discuss with us, feel free to call our director Sara Bluming at 240-621-0770 or email sara@chabadpotomac.com.

Teen Profile
 
Last Name
First Name
Hebrew Name
Age
DOB
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.
School
Grade Entering
 
 
Parent Information
 
Address
City/Zip
Phone
Father's Name
Father's Occupation
Father's Cell
Father's Email
Mother's Name
Mother's Occupation
Maternal Grandmother born Jewish?
Mother born Jewish? Converted by whom?
Mother's Cell
Mother's Email
Emergency Information
 
Emergency Contact 1
Phone
Emergency Contact 2
Phone
Doctor's Name
Doctor's Phone Number
Medical Insurance Company
Policy 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.


Registration Payment Agreement
 
Registration fee is $100/child; Payment for Hebrew School tuition is by check or cash. If you choose to pay by credit card, please use the "Tuition Payment page" which automatically adds the 3.5% credit card fee which we incur. Tuition payment is due in full by September 1, 2017 or half by September 1 and half by January 15, 2018. Tuition for the year, per child: $850 (Discount: 10% for each additional child)

 


Please check box with your choice for method of payment.
Prepayment in full before September 1st
Pay ½ of tuition before September 1st, and ½ by January 15.
Other method of payment as arranged with the office.
 
Tuition payments can be made by clicking here

>

Method of Registration Payment:

Credit Card (form below)
Check (Please mail checks to Chabad of Potomac, attn: Mrs. Sara Bluming, director, 11826 Seven Locks Rd, Potomac MD 20854 )

Registration Payment
CC Type   Card Number
Billing Address   City, State, Zip
CVV   Exp Date

Total Registration Cost:

Agreement
 
As the parent(s) or legal guardian of the above child, I/we authorize any adult acting on behalf of CTeen Jr. 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, CTeen Jr. 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 CTeen Jr. activities and that these pictures may be used for marketing purposes.

I Accept
I grant my child permission to join all Cteen Jr. trips and transportation to trips.

Name: Initials: Date:

 

Secure This page uses 128 bit SSL encryption to keep your data secure.