Returning Student Registration

Please fill out all fields below. If you prefer, you can print a PDF by CLICKING HERE

Please fill out all REQUIRED FIELDS, and any other UPDATED/NEW info.

Your Name:*

First NameLast Name

Full Name*

First NameLast Name

Hebrew Name:

Gender:

Grade entering in September:*

Birth Date

MonthDayYear

Time of Day:

HourMinutes

School Currently Attending:*

All family information is the same as the first child.

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Home Phone Number:

Area CodePhone Number

Father's Name:

Hebrew Name:

Work Phone Number:

Area CodePhone Number

Cell Phone Number:

Area CodePhone Number

Father's Occupation:*

Mother's Name:

Hebrew Name:

Work Phone Number:

Area CodePhone Number

Cell Phone Number:

Area CodePhone Number

Mother's Occupation:*

Mother's E-mail:

Father's E-mail:

Which email would you like used for updates and newsletters?

Mother'sFather'sBoth

Marital Status:

MarriedSingleDivorced

Previous Jewish Education:

Does your child read basic Hebrew?

NoneSomewhatWell

Does your child have any learning difficulties with General Studies?*

YesNo

If yes, please describe:

Does your child have an IEP?*

YesNo

*If yes, please submit a copy with the registration form.

Is the natural mother of the child Jewish?

YesNo

Is the natural father of the child Jewish?

YesNo

Is the maternal grandmother of the child Jewish?

YesNo

Are there any conversions and/or adoptions in the family?

YesNo

Is there any special medical or other information that we should be aware of?*

YesNo

If yes, please describe:

Does your child have any allergies?*

YesNo

Is your child currently taking any medication?*

YesNo

Family Physician:*

Physician's Phone Number:

Area CodePhone Number

Medical Insurance Company:

Policy #:

Emergency Contact #1:

Relation:

Phone Number:

Area CodePhone Number

Emergency Contact #2:

Relation:

Phone Number:

Area CodePhone Number

Medical Release:*

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

Grandparent(s) Full Name(s):

Maternal or Paternal?

Address:

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Phone Number:

Area CodePhone Number

E-mail:

Grandparent(s) Full Name(s):

Maternal or Paternal?

Address:

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Phone Number:

Area CodePhone Number

E-mail:

*

I hereby give permission to my child to participate in all school outings and field trips beyond school properties and to use any transportation selected by the Chabad Hebrew School.I grant permission for my child to be photographed in individual or group pictures which may be used by Chabad Hebrew School for P.R.

Student Information:

Family Information:

Religious and Educational:

Medical Information:

Grandparent Information:

Permission Slips:

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