JewQ Advanced Hebrew School Registration

My Child Attends Chabad Five Towns Sunday Hebrew School Program*

YesNo

Number of Children Registering:*

Child Name*

First NameLast Name

*

MaleFemale

Hebrew Name

Birth Date*

Date

My child was born in the*

MorningEvening

I am registering my child for:

Sunday Hebrew SchoolTuesday Hebrew SchoolTuesday - JewQ Track

Child's School for 2025 - 2026*

Child's Grade for 2025 - 2026*

Does your child have an IEP?*

YesNo

Please specify any medical or behavioral concerns that we should be aware of:*

By sharing this information, you help us help your child.

Has your child previously attended Jewish school or Hebrew School*

YesNo

Please specify:*

Does your child have any allergies? What should be done in the case of an allergic reaction?*

Child Name*

First NameLast Name

*

MaleFemale

Hebrew Name

Birth Date*

Date

My child was born in the*

MorningEvening

I am registering my child for:

Sunday Hebrew SchoolTuesday Hebrew SchoolTuesday - JewQ Track

Child's School for 2025 - 2026*

Child's Grade for 2025 - 2026*

Does your child have an IEP?*

YesNo

Please specify any medical or behavioral concerns that we should be aware of:*

By sharing this information, you help us help your child.

Has your child previously attended Jewish school or Hebrew School*

YesNo

Please specify:*

Does your child have any allergies? What should be done in the case of an allergic reaction?*

Child Name*

First NameLast Name

Hebrew Name

*

MaleFemale

Birth Date*

Date

My child was born in the*

MorningEvening

I am registering my child for:

Sunday Hebrew SchoolTuesday Hebrew SchoolTuesday - JewQ Track

Child's School for 2025 - 2026*

Child's Grade for 2025 - 2026*

Does your child have an IEP?*

YesNo

Please specify any medical or behavioral concerns that we should be aware of:*

By sharing this information, you help us help your child.

Has your child previously attended Jewish school or Hebrew School*

YesNo

Please specify:*

Does your child have any allergies? What should be done in the case of an allergic reaction?*

How did you hear about Chabad of Five Town's Hebrew School?*

Was the birth mother born Jewish?*

YesNo

Were there any conversions or adoptions in the family?*

YesNo

Please specify*

Who was the Rabbi?*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Mother Name*

First NameLast Name

Mother Cell Number*

Please enter a valid phone number.Format: (000) 000-0000.

Mother E-mail*

example@example.com

Father Name*

First NameLast Name

Father Cell Number*

Please enter a valid phone number.Format: (000) 000-0000.

Father E-mail*

example@example.com

Marital Status*

MarriedSeperatedDivorced

Emergency Contact*

First NameLast Name

Cell Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

Relationship *

As the parent(s) or legal guardian of the above child, I/we authorize any adult acting on behalf of Chabad of the Five Towns Hebrew School 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 Hebrew School personnel will try, but are not required, to communicate with me prior to such treatment. I hereby give permission for my child to attend all field trips and outings sponsored by Chabad of the Five Towns Hebrew School.

Signature

Accident: As the parent(s) or legal guardian of the above child/ren, I/we authorize any adult acting on behalf of Chabad Five Towns Hebrew School 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 Five Towns Hebrew School personnel will try, but are not required, to communicate with me prior to such treatment.

Privacy: I hereby give permission for my child’s photographs/videos to be used in newsletters, local newspapers, Chabad Five Towns website or for promotion of our program.

Signature

Tuesday Advanced JEWQ Track - $300
If your child attends Chabad Five Towns Sunday Track the cost is $180 - please use coupon code SUNDAY below to receive the discount

Registration *

Tuesday - JEWQ Track Tuition

This option is for children in grades 4-6 to join our ADVANCED JEWQ TEXT BASED TRACK

$300.00 Number of Children Registering

JewQ Sponsor

I would like to make an additional donation to Chabad Five Towns JewQ Programs - Please choose an amount below - if you would like to make a donation of a different amount please call the office: 516-295-2478

$100.00

Enter coupon

Total

$0.00

Credit Card

First Name

Last Name

Credit Card Number

Security Code

Expiration Month

Expiration Year

Billing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Child 1

Child 2

Child 3

Parent Information

Emergency Information

Disclaimer

Payment