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Register Online

Register Online

Registration Form

We are currently accepting application forms for the 2017-2018 school year. Please fill out ALL fields of this form. Confirmation of acceptance will be acknowledged only after this registration form is reviewed and an acceptance email is received.  If you have any questions or concerns you'd like to discuss with us, please contact us at: 951-222-2005.

STUDENT INFORMATION
CHILD 1
First Name   Last Name
Hebrew Name   D.O.B.
Age   Gender  Boy  Girl
School   Grade Entering
CHILD 2
First Name   Last Name
Hebrew Name   D.O.B.
Age   Gender  Boy  Girl
School   Grade Entering
       
Is the natural mother of the Child(ren) Jewish?    
Were there any conversions or adoptions in the Family?  Yes       No    If Yes - please explain   
Previous Jewish Education  Yes        No             If yes - where? 

PARENT INFORMATION 
Father's Name   Hebrew Name
Home Phone   Father's Cell
Father's Email   Occupation:
Mother's Name   Hebrew Name
Home Phone   Mother's Cell
Mother's Email    Occupation
Address   City, State, Zip
Synagogue affiliated with:         

MEDICAL INFORMATION 
Persons to be contacted in case of an emergency when parents cannot be reached: 
(Please provide at least two contacts)
Name   Relationship to child
Phone      
Name   Relationship to Child
Phone      
Family Physician   Phone

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.  

    
As the parent(s) or legal guardian of the above child, I/we authorize any adult acting on behalf of Chabad Jewish Community Center of Riverside 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 Jewish Community Center of Riverside 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 participate in all school activities, join in class and school trips on and beyond school properties and allow my child to be photographed while participating in Chabad Jewish Community Center of Riverside Hebrew School activities and that these pictures may be used for spreading awareness about our school.  

 I Accept    

Name:
      Initials:   

PAYMENT OPTIONS

Full tuition: $529.00 • In advance by Aug. 31 $476.00 
Includes registration fee, books and all supplies.  


Discounts: 
10% discount off for each additional child of the same family. 
10% additional discount off your total tuition for each child of another family you successfully introduce to the school.

Please choose one of the following payment options:

  1. One Full Tuition Payment
  2. Three equal payments charged on the first of the month October - December

Payment Method:  
Credit Card  eCheck

Credit Card Information:
Name on card   Card Type  
Charge Amnt.   Card Number
Exp. Date      CVV Code   3 digits on back of card

eCheck Bank Details:
Bank Routing Number   Checking Account Number  
Bank Name   Name on Bank Account  
Charge Amnt.      
 

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