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 contact us at shterna@elginchabad.com or 847-693-8799

Student 1 Profile
First Name 
Last Name 
Hebrew Name 
Age 
DOB 
 

In Judaism the day begins at nightfall, so to determine the exact date of the Jewish birthday we need to know the time of day.
School 
Grade Entering 
  Previous Jewish Education 
 Yes  No
Where? 
Does your child have any learning difficulties?Please specify 

This information will help us better cater to the needs of your child.
Does your child have any special abilities, habits. behaviors or anything else which you want us to be aware of?

This information will help us better cater to the needs of your child.
 
Student 2 Profile
First Name 
Last Name 
Hebrew Name 
Age 
DOB 
Time of Birth 

In Judaism the day begins at nightfall, so to determine the exact date of the Jewish birthday we need to know the time of day.
School 
Grade Entering 
  Previous Jewish Education 
 Yes  No
Where? 
Does your child have any learning difficulties?Please specify 

This information will help us better cater to the needs of your child.
Does your child have any special abilities, habits. behaviors or anything else which you want us to be aware of? 

This information will help us better cater to the needs of your child.
 
Student 3 Profile
First Name 
Last Name 
Hebrew Name 
Age 
DOB 
Time of Birth 

In Judaism the day begins at nightfall, so to determine the exact date of the Jewish birthday we need to know the time of day.
School 
Grade Entering 
  Previous Jewish Education 
 Yes  No
Where? 
Does your child have any learning difficulties?Please specify 

This information will help us better cater to the needs of your child.
Does your child have any special abilities, habits. behaviors or anything else which you want us to be aware of? 

This information will help us better cater to the needs of your child.
Family Information
My child is a 
Are the natural father, mother and maternal grandmother of the child Jewish?  Yes  No 
If no, please explain. 

Have there been any conversions or adoptions in the family?  Yes No 
If yes, please explain.  

Please provide any necessary documentation for conversions or adoptions

Parent Information
Father's Name
Cell 
Email
Mother's Name 
Cell 
Email
Address 
City 
Zip 
Home Phone 
 
   
* Email allows us to communicate in the most efficient and economical manner. We do not use your address for other purposes.

Does either parent have any special skill or resource to offer our children or teachers?

 

Emergency Information
Emergency Contact 1 
Phone 
Relationship 
Emergency Contact 2 
Phone 
Relationship 
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. 
Tuition Agreement

Tuition for the fall course:

$75 per child
$135 for 2 children

At Chabad we are committed to providing a Jewish education for every Jewish child. If other payment arrangements are necessary, please call us and we will be happy to help. 

Please Note - Acceptance to the school is pending director's approval. 

Payment Information
Payment Method  

Checks can be mailed to 30W509 Shoe Factory Rd. Elgin, IL 60120-9245  

Total Registration Cost   Card Number
Expiration   CVV
Additional Comments (optional):  
Terms of Agreement
 I agree that in the event of an emergency, Jewish Kids Club has my permission to arrange for any necessary first-aid or care by a licensed physician/first-aid worker. Jewish Kids Club has my permission to use my child's photo in its publicity materials. I give permission for my child/ren to attend all field trips and outings sponsored by Jewish Kids Club. I have completed the Enrollment Form and agree to pay any balance according to the terms of agreement outlined above. 
Name: 
Initials: 

We look forward to a wonderful year of learning and growth!