Registration

Click here to register!
Is this the first time registering this child for Hebrew School of the Arts?

Yes, first time!No, we registered him/her in previous years
Please fill out this form and submit it together with your tuition, registration and book fees.
General Information:
Child's Full Name:*
Child's Hebrew Name: *
Child's Preferred Name:*
Birth Date:*

Month Day Year
E-mail to be used for all communications:*

Address*

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

Home Phone Number:

Area Code Phone Number
Which school does your child attend?
Child’s grade for the new school year
Religious & Educational History:
Does your child read basic Hebrew?*

Learned Alphabet in the pastExperience
Does your child have any difficulty with his general studies?
Is Your Child's Mother Jewish?*

Yes (If adopted/converted, please specify belowNo
Are there any adoptions in your family (children, parents or grandparents)?
Have you or your spouse, parents, grandparents or children ever converted to Judaism?
Contact Information:
Father's Name:*
First Name Last Name
Father's Hebrew Name*
Work Phone Number:*

Area Code Phone Number
Other Phone Number:

Area Code Phone Number
Occupation:*
Mother's Name:*
First Name Last Name
Mother's Hebrew Name:*
Work Phone Number:*

Area Code Phone Number
Other Phone Number:

Area Code Phone Number
Occupation:*
Emergency Contact Person:(other than parent/guardian)
Full Name
First Name Last Name
Relationship to child:
Daytime Phone Number:

Area Code Phone Number

Address

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

Authorized Persons To Pick Up Your Child: (other than parents/guardians)
Full Name #1:
First Name Last Name
Daytime Phone Number:

Area Code Phone Number
Evening Phone Number:

Area Code Phone Number

Address

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

Full Name #2:
First Name Last Name
Daytime Phone Number:

Area Code Phone Number
Evening Phone Number:

Area Code Phone Number

Address

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

Method of Payment:
Payment Options:

Payment in Full $750($700 Tuition. $50 Registration & Book Fee.)Ten Equal Payments - $75Registration Fee Only -I'd Like to Request Financial Aid ($50 one time)
Total

$0.00

Payment

Credit Card Paypal Check Payment

Postal / Zip Code

Country

Click HERE to apply for the scholarship.
Signature:*
Date:*

Month Day Year
Medical Information:
Name of Child's Physician:
Physician's Phone Number:

Area Code Phone Number

Physician's Office Address:

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

Insurance Company Covering the Child
Policy Number:
Expiration Date:

Month Day Year
Please list below any psychological or medical conditions, medications currently being taken, dietary requirements, allergies(include allergies to medications), etc. pertaining to your child.
I hereby give permission, in the event of an emergency, for the Director, the Acting Director, or the Teacher at Chabad of Venice to take whatever steps maybe necessary for the medical care of my child. I understand that in order for Chabad of Venice 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:I give consent to any emergency facility and physician to administer any necessary medical treatment to my child as the situation may warrant it.
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 accompanied 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.
Parent/Guardian's Signature:
Date:

Month Day Year
100% of the proceeds of this donation or payment benefit Chabad of Venice & North Port.
Should be Empty:

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