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Student Information
CHILD 1
Last Name
First Name
Hebrew Name
Gender
Male Female
Date of Birth
School
Grade
Previous Jewish education?
Yes No
If Yes please describe
Medical Information -
Any Medical Challenges?
Yes No
If Yes please explain
 
CHILD 2
Last Name
First Name
Hebrew Name
Gender
Male Female
Date of Birth
School
Grade
Previous Jewish education?
Yes No
If Yes please describe
Medical Information -
Any Medical Challenges?
Yes No
If Yes please explain
 
CHILD 3
Last Name
First Name
Hebrew Name
Gender
Male Female
Date of Birth
School
Grade
Previous Jewish education?
Yes No
If Yes please describe
Medical Information -
Any Medical Challenges?
Yes No
If Yes please explain
 
Parent Information

Father

Title/First Name
Last Name
Work Phone
Cell Phone
Occupation
Email
Mother
Title/First Name
Last Name
Work Phone
Cell Phone
Occupation
Email
Parents
Address
City/State/ Zip
Home Phone
Affiliation
Have there been any adoptions or conversions in the family (e.g., the child, parents, grandparents)
Yes No
If yes, please explain and indicate which synagogue the conversion took place
Emergency Information
Emergency 1
Name
Phone #
Relation
Emergency 2
Name
Phone #
Relation
Tuition Fees
Please contact Miriam Ferris at (510) 684-5292, to discuss any issues or concerns. In person classes are held at Chabad Berkeley Jewish Center - For Online Zoom Class contact us for more info
Tuition: $650
5% Discount for a friend referral | Friend's Name
Payment Information
Please Choose Payment Plan
For Check Payments: Please mail to Chabad Berkeley Hebrew School: P.O. Box 5292 Berkeley, CA 94705
I would like to assist a child who cannot afford Hebrew School Education.
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