We are currently accepting application forms for the 2019/2020 school year.

Please fill out this form to the best of your ability. If you have any questions or concerns you'd like to discuss with us, please contact us.

Please note that this registration form can be used for three children.

We look forward to a wonderful year of learning and growth.

Registration 
 

Child's Profile

Name of Child #1: Age:

Birth Date:

Hebrew Name:

Name of Day School: Grade:


Name of Child #2: Age:

Birth Date:

Hebrew Name:

Name of Day School: Grade:


 

Name of Child #3: Age:

Birth Date:

Hebrew Name:

Name of Day School: Grade:


Parents' Information
 

Mother Address:

Father Address (if different):

Mother Cell: Email:

Father Cell: Email:

Mother's Hebrew/English Name:

Father's Hebrew/English Name:

Is the biological mother Jewish by birth? yes no

Is the biological father Jewish by birth? yes no

Did either parent have any Jewish schooling?    yes no

Has there been a conversion or adoption in the family or extended family?
  
yes no  If yes, please specify:

Medical Information

Does your child(ren) have any learning challenges:    yes no


Does your child(ren) have a medical condition or allergy we should be aware of?    yes no  If yes, please specify:


Emergency Contact Information and Medical Consent

In case of an emergency, when parents cannot be reached, please contact:

Emergency Contact:

Phone:

Relationship to child  

Family Physician  

Phone Number  

Please enroll our child in the Jewish Kids Club

In the event of a medical emergency and neither parent can be reached, medical treatment may be provided as necessary.

I (we) hereby permit my child to participate in all school activities, join in class and school trips on and beyond school properties.

I (we) hereby allow my child to be photographed while participating in the Chabad Jewish Kids Club activities and that these pictures may be used for marketing purposes.


Name:

 


Payment Information

Membership: $280 for full year • Second child: $250

Please charge my credit card full payment for the year: $

 

Credit Card Number:  Exp.  CVV

Will pay by check

We look forward to a wonderful year of learning and growth!