Chabad Hebrew School - Registration

Student Profile

Last Name

First Name

Hebrew Name

Age

DOB

School

Grade Entering

Hebrew Reading Proficiency

Previous Jewish Education

Yes

No

Where?

Parent Information

Address

City/Zip

State

Father's name

Father's Occupation

Father's Cell

Email

Mother's Name

Mother's Occupation

Mother's Cell

Emergency Contact Information

Emergency Contact 1

Phone

Emergency Contact 2

Phone

Doctor's Name

Doctor's Phone Number

Medical Insurance Company

Policy Number

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.

Registration Payment Agreement

Scholarship application available upon request here

Payment Method

Registration Payment

Type

Number

Expiration

Code

Use contact info above

Name

Address

Zip

As the parent or legal guardian of the above child:

In the event of an emergency, I authorize any adult acting on behalf of Chabad Hebrew School to hospitalize or secure treatment for my child, and I further agree to pay all related charges. It is understood that if time and circumstances permit, Chabad Hebrew School personnel will try, but are not required, to communicate with me prior to such treatment.

I give permission for my child to participate in and out of the Chabad Center, and allow my child to be photographed while participating in Chabad Hebrew School activities, knowing that these pictures may be used for marketing purposes.

All registration pending confirmation from CHS administration.

I Accept

Name:

Initials:

Date:

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