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Register Online: CHS Starts on Monday, September 19, 2016

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 Sarah 561-222-4083 or

Student Profile
Last Name
First Name
Hebrew Name
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.
Grade Entering
Parent Information
Mother's Name
Mother's Cell
Mother's Email Address
Father's Name
Father's Cell
Father's Email Address
Emergency Information
Emergency Contact 1
Emergency Contact 2
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
Tuition for the year, per child: $300

Method of Registration payment:

1 payment by Credit Card (form below) 3 Payments by Credit Card Charged Automatically (form below)

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

Total Registration Cost:

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 trips and transportation to trips.

Name: Initials: Date:


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