Chabad Central Hebrew School Registration Form 2016-2017
Student's Hebrew Name (If known):
Birth Date: Time of day born:
Current Grade Entering:
Home Telephone Number:
School Name and Town:
Father's Cell Number:
Mother's Cell Number:
Names and ages of other children in family:
ABOUT YOUR CHILD:
Does your child read basic Hebrew?
Previous Religious School Education:
Does your child have any learning difficulties with general studies? Please explain:
Is there anything you want us to know about your child that would help us to help him/her:
Mother Jewish yes no
Father Jewish yes no
Were there any conversions in the family? yes no
If yes, please elaborate:
Is the child adopted? yes no
Does either parent have any special resources or skills to offer our children or teachers?
We grant permission for our children to be photographed in an individual or group picture which may be used by the school for PR purposes (names of children are never
released). Agree or Disagree:
Please list all names of people who are authorized to take child to and from school:
MEDICAL EMERGENCY INFORMATION:
In case of emergency, when neither parent can be reached, provide names of TWO people who will take responsibility for your child:
If parents cannot be reached and emergency medical advice is needed, permission is given to the Hebrew School staff to phone my child's doctor. Agree or Disagree:
Doctor's Hospital Affiliation:
In case of medical emergency requiring immediate emergency care, I authorize to take my child to the hospital, if necessary. Agree or Disagree:
FURTHER MEDICAL INFORMATION:
Allergic reactions to medication:
Medication child is taking on a regular basis:
Any special medical circumstances or allergies:
Security Fee: $ 50
Book Fee: $ 36
I understand that my credit card will be charged in equal installments beginning at the time of enrollment.
Please charge my credit for the full amount due.
I will be submitting a check for the full amount and/or checks divided over the remaining months of school.
City, State, Zip:
Amount to charge:
Name on Card:
Credit card number:
Checks can be mailed to: Chabad of Boca Raton 17950 Military Trail Boca Raton, FL 33496
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