Registration Application 2017-18

 

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: