Registration

Home Address*

Biological Mother is*

Jewish at birthConvertedAdoptedNone
Biological Father is*

Jewish at birthConvertedAdoptedNone
Maternal Grandmother is*

Jewish at birthConvertedAdoptedNone
Student Information
CHS is for children ages 4-10. Please fill out a separate form for each child.
Student's Name*
First Name Last Name
Hebrew Name
Date of Birth*

Month Day Year
To calculate Hebrew birthday, please enter approx. time of birth
Hour Minutes
School attending, Grade (Fall '25)*
Summarize your child's previous Jewish education/knowledge*
Please list any allergies, health issues, medications, or any other info we need to know:*
Does your child recieve any individualized assistance at school? If yes, please explain.
Emergency Contact Information
Emergency Contact*
First Name Last Name
Phone Number*

Area Code Phone Number
Parental Consent
Emergency Permission*

I hereby permit CHS to obtain emergency medical care for my child if needed, at my expense.
Photo Release*

I allow CHS to use photographs/video of my child for promotional purposes.
Payment Information
Choose A Plan*

Plan 1: One Payment of $800 for the yearPlan 2: Two payments: $400 at sign-up, remainder to be charged Jan. 5Plan 3: Eight payments: $100 at sign up, remainder to be charged on the 5th every month
Total

$0.00

Payment*

Credit Card

We accept Visa, MasterCard, American Express, Discover
Credit Card Number	Security Code
Name on Card
Expiration Month	Expiration Year

Billing Address

Street Address

City

State / Province

Postal / Zip Code

Country

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Family Information