Hebrew School Free Registration

Student Information:

Number of children being registered: *

Name (Child 1): *

First

Last

Hebrew Name (if known):

Date of Birth: *

School: *

Age: *

Current Grade: *

Name (Child 2) *

First

Last

Hebrew Name (if known):

Name (Child 3): *

First

Last

Hebrew Name (if known):

Home Phone:

Address

Address Line 1

Address Line 2

City

State

Zip Code

Does your child have any difficulties with his/her general studies? If yes, please specify:

Parent Information:

Parent 1 Name: *

First

Last

Hebrew Name (if known):

Parent 1 is:

Jewish by Birth
Jewish by Choice
Not Jewish

Phone Number: *

E-mail: *

Occupation:

Work Address:

Address Line 1

Address Line 2

City

State

Zip Code

Parent 2 Name: *

First

Last

Hebrew Name (if known):

Parent 2 is:

Jewish by Birth
Jewish by Choice
Not Jewish

Phone Number: *

E-mail: *

Occupation:

Work Address:

Address Line 1

Address Line 2

City

State

Zip Code

Medical Information:

Are your children up to date with vaccinations? *

Yes
No

Date of last tetanus shot (Child 1): *

Date of last tetanus shot (Child 2): *

Date of last tetanus shot (Child 3): *

Allergies:

Medical Conditions, if any:

Name of Doctor: *

First

Last

Phone: *

Doctor's Address:

Address Line 1

Address Line 2

City

State

Zip Code

Medical Insurance Provider: *

Policy Number: *

Emergency Information:

First Contact Person In Case Of Emergency

Name: *

First

Last

Relationship:

Phone Number: *

Second Contact Person In Case Of Emergency

Name: *

First

Last

Relationship:

Phone Number: *

Permissions

Permission for Emergency Medical Treatment

I authorize any adult acting on behalf of the The Bear Family Las Olas Chabad Hebrew School to hospitalize or secure treatment for my child/children. I further agree to pay for all charges for that care and/or treatment. It is understood that, if time and circumstances reasonably permit, The Bear Family Las Olas Chabad Hebrew School will try to communicate with me prior to such treatment.

I agree

I hereby give permission for my child to attend all field trips sponsored by the The Bear Family Las Olas Chabad Hebrew School

I permit my child's photos to be used by The Bear Family Las Olas Chabad Hebrew School for publicity purposes.

Signature: *

Date:

Tuition Payment:

Comments: