Registration Application
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: