Contact Information
Mother's Name
Mother's Jewish Name
Mother's Email
Mother's Cell
Father's Name
Father Jewish Name
Father's Email
Father's Cell
Address
City
State & Zip
Teen Information
How many teens are you registering?
One
Two
Teen Name
Hebrew Name
Date of Birth
Grade
Please select
8th Grade
9th
10th
11th
12th
Teen Name #2
Hebrew Name
Date of Birth
Grade
Please select
8th
9th
10th
11th
12th
Registration Information
Jteen Tuition is $250 per Teen.
Number of teens being registered
Payment Info
Type
Visa
MC
Amex
Discover
Number
Expiration
Code
Use contact info above
Name
Address
Zip
Medical Emergencies
I authorize the director or director's designee to seek appropriate medical care for my child, if necessary.
Emergency Contact
In case of emergency, when neither parent can be reached, give name of who will take responsibility for your child:
Full Name
Address
City
State
Zip
Phone
Email
Work
Relationship to child
Medical Agreement
In case of medical emergency requiring immediate emergency care, I authorize the paramedics to take my child to the nearest hospital if necessary. It is understood that I will hold Chabad Hebrew School of Monmouth County harmless for the nature and outcome of any emergency medical treatment. It is also understood that I leave the decision of what constitutes an emergency to the sole direction of the staff (please sign)
Register
This site is protected by reCAPTCHA and the Google
Privacy Policy
and
Terms of Service
apply.
This page uses SSL encryption to keep your data secure.