Registration - Chabad of Northampton

Family Information
Parent 1 Name*
First Name Last Name
Parent 1 E-mail*
Parent 1 Phone Number*
Parent 2 Name
First Name Last Name
Parent 2 Email
Parent 2 Phone Number
Please select all that apply*

Biological father is JewishBiological mother is JewishOther
If other, please explain*
Are there any adoptions or conversions in the family?*

YesNo
If yes please explain:*
How did you hear about our program?
Student Information
Number of students I would like to register* $25 EARLY BIRD Registration Fee per Child until July 15, $50 after that
Student 1 - Full Name*
First Name Last Name
Student 1 - Help us get to know your child, please upload a recent photo.*
Student 1 - Date of Birth*

Month Day Year
Student 1 - Grade Entering*
Student 1 - Please let us know about your child's Aleph Bet/Hebrew knowledge*
Student 1 - Please list any allergies or medical conditions we should be aware of
Student 2 - Full Name*
First Name Last Name
Student 2 - Help us get to know your child, please upload a recent photo*
Student 2 - Date of Birth*

Month Day Year
Student 2 - Grade Entering*
Student 2 - Please let us know about your child's Aleph Bet/Hebrew knowledge*
Student 2 - Please list any allergies or medical conditions we should be aware of
Student 3 - Full Name*
First Name Last Name
Student 3 - Help us get to know your child, please upload a recent photo*
Student 3 - Date of Birth*

Month Day Year
Student 3 - Grade Entering*
Student 3 - Please let us know about your child's Aleph Bet/Hebrew knowledge*
Student 3 - Please list any allergies or medical conditions we should be aware of
Help Our Community Grow
Do you know another family who might enjoy Bar Lavi Hebrew School? Share their information with us below. If they enroll, you'll receive a tuition credit as our thank you for helping our community grow.
Full Name
First Name Last Name
Phone Number
E-mail
Payment
Tuition Information:
EARLY BIRD: $25 Registration fee per child until July 15th
$50 Registration fee per child
$1,000 per year per child - includes books and supplies
Payment options*

You may pay the entire amount of $1,025 per student in full nowYou may pay the $25 registration fee per student now, and split tuition payment into two parts. First payment of $500 per student is due in September and second payment of $500 per student is due in JanuaryYou may pay the $25 registration fee per student now, and contact us to set up a payment plan for tuition.
I will be submitting our full tuition obligation now for the following number of students $1,025 per student, including registration fee
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

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

Student Information

Help Our Community Grow

Payment