Registration Application 2018-19

 

Please Print Clearly:

 Part 1: Student Information

 Last Name:     First Name: 

Hebrew Name: 

Address:   City: 

State:  Zip: 

Phone: 

Birthday:  Age:

Grade Entering: 

 

Part 2: Parents' Information

 Father's Name:   Hebrew Name: 

Occupation:   Work Address: 

Phone:    Email: 

Cell:

 

Mother's Name:    Hebrew Name: 

Occupation:   Work Address: 

Phone:   Email: 

Cell:

 

Part 3: Religious & Educational History

Previous Hebrew Education: 

Are the child's natural parents Jewish by birth? I

If no, please explain: 

Were there any conversions /adoptions in the family?

Where was the conversion done? Who was the Rabbi who performed the conversion?

 

Part 4: Medical Information (confidential)

 Up to date with vaccinations? 

Any other special medical or other information, which we should be aware of, including allergies?

 

Part 5: Referrals

 How did you hear about Chabad Hebrew School? 

 

Emergency Contact Information

Person to be contacted in case of an emergency when parents cannot be reached:

Name:   Phone: 

Relationship to child:   C ity/Town: 

Family Physician:   Phone: 

Medical Insurance Co.:  Policy:

 

Medical Release Form:

I, hereby, give consent to the administration of the Chabad Hebrew School to take whatever medical measures they seem necessary, at my expense, for my child in the event of a medical emergency.

Signature of Parent: 

Date: