Registration Application 2018-19

Please Print Clearly:

 Part 1: Student Information

 Last Name:     First Name: 

Hebrew Name: 

Address:   City: 

State:   NJ   NY   PA   Zip: 

Phone: 

Birthday:  Age:  5   6   7   8   9   10   11   12   13  

Grade Entering:   Kdg.   1   2   3   4   5   6   7   8  

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?   Yes   No  I

If no, please explain: 

Were there any conversions /adoptions in the family?  Yes   No  

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

Part 4: Medical Information (confidential)

 Up to date with vaccinations?   Yes   No  

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?   Ad   Friend   Newspaper   Mailing   Something else  

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: