Student Information CHILD 1 Last Name First Name Hebrew Name Gender Male Female Date of Birth School Grade Grade Entering Kindergarden Grade 1 Grade 2 Grade 3 Grade 4 Grade 5 Grade 6 Grade 7 Grade 8 Previous Jewish education? Yes No If Yes please describe Medical challenges or allergies? Yes No If Yes please explain CHILD 2 Last Name First Name Hebrew Name Gender Male Female Date of Birth School Grade Grade Entering Kindergarden Grade 1 Grade 2 Grade 3 Grade 4 Grade 5 Grade 6 Grade 7 Grade 8 Previous Jewish education? Yes No If Yes please describe Medical challenges or allergies? Yes No If Yes please explain CHILD 3 Last Name First Name Hebrew Name Gender Male Female Date of Birth School Grade Grade Entering Kindergarden Grade 1 Grade 2 Grade 3 Grade 4 Grade 5 Grade 6 Grade 7 Grade 8 Previous Jewish education? Yes No If Yes please describe Medical challenges or allergies? Yes No If Yes please explain Parent Information Marital Status - Select - Married Separated Divorced Affiliation Father Title/First Name Dr. Mr. Last Name Work Phone Cell Phone Email Jewish Yes No Converted Yes No Mother Title/First Name Mrs. Dr. Ms. Last Name Work Phone Cell Phone Email Jewish Yes No Converted Yes No Parents Address City/State/ Zip Home Phone Emergency Information Emergency 1 Name Phone # Relation Emergency 2 Name Phone # Relation Tuition Fees Classes are held on Sundays at Chabad Jewish Center of Petaluma 10:00 AM - 11:30 AM Rate A: $750.00 | Rate B: $650 | Child Two - 10% Off Scholarships Every Jewish child deserves a quality education. Contact us at 707.559.8585 and we will be glad to help. If you are in the position to contribute to the scholarship fund, please consider doing so below. $180 Half Scholarship - $325 Full Scholarship - $650 Other amount $ Payment Information Please Choose Payment Plan Pay in Full Three Payments Six Payments - Select Plan - Please Choose Payment Method - Select Method - Cash Check Visa Mastercard Card Number Name on Card Expiration Date Month 01 - Jan 02 - Feb 03 - Mar 04 - Apr 05 - May 06 - Jun 07 - Jul 08 - Aug 09 - Sep 10 - Oct 11 - Nov 12 - Dec Year 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 Security Code What's This? Billing Address Billing Zip - Enrollment and acceptance in Petaluma Hebrew is in not a certification of Jewish status - This page uses 128 bit SSL encryption to keep your data secure.
