Hebrew School Registration Form

Part I:  Student Information
Last Name   First Name  
Hebrew Name   Email (child's)  
Address   City  
State   Zip  
Phone   Birthday  
Age   School  
Grade (Entering)      
Part II:  Parents' Information
Father's Name   Hebrew Name  
Work Address   Phone  
Mother's Name   Hebrew Name  
Work Address   Phone  
Email (parent)   Synagogue Affiliation  
Father Cell   Mother Cell  
Part III:  Religious & Educational History
Previous Hebrew Education  
Were there any conversions &/or adoptions in the family  Yes   No
If yes, what relation to the family  
Where was the conversion done?  Who was the Rabbi who performed the conversion.  
Part IV:  Medical Information (confidential)
Up to date with vaccinations   Yes   No  
Any special medical or other information, which we should be aware of including allergies?   
Part V:  Program
Hebrew School   Private Tutoring  
I hereby permit my child to participate in all school activities, and to join in class and school trips on and beyond school properties and use any transportation selected by the 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   City/Town  
Family Physician   Phone  
Medical Insurance Co   Policy Number  
Medical Release Form:
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.
Name of Parent   Date