Family Information Form

BEFORE YOU FILL THIS FORM YOU MUST COMPLETE THE APPLICATION FORM
Click Here  

 
Family Name      
Address   City  
Zip Code   Home Phone  
Father's Name   Hebrew if Available  
Address (if different)   City  
Zip Code   Home Phone  
Father's Email   Father's Cell Phone  
   

 Cell Phone Carrier

  
Mother's Name   Hebrew if Available  
Address (if different)   City  
Zip Code   Home Phone  
Mother's Email   Mother's Cell Phone  
    Cell Phone Carrier  
Marital Status of Parents   Does someone other than the parent(s) care for your child(ren)?  
If yes, please give name   Phone Number  

Are both parents Jewish? Yes No 
To your recollection have there been any conversions or adoptions in the family? No Yes 

If yes please explain :
Child Information
Attending Chabad Hebrew Scool    
1. Child's Name   Hebrew Name  
DOB   Hebrew DOB (if not known, please indicate time of birth)  
Grade Entering   Anything we should know about your child:   
Any allergies
Attending Chabad Hebrew Scool    
2. Child's Name   Hebrew Name  
DOB   Hebrew DOB (if not known, please indicate time of birth)  
Grade Entering    Anything we should know about your child:  
Any alleriges
Attending Chabad Hebrew Scool    
3. Child's Name   Hebrew Name  
DOB   Hebrew DOB (if not known, please indicate time of birth)  
Grade Entering    Anything we should know about your child:  
Any alleriges
Attending Chabad Hebrew Scool    
4. Child's Name   Hebrew Name  
DOB   Hebrew DOB (if not known, please indicate time of birth)  
Grade Entering    Anything we should know about your child:  
Any alleriges
Please list name and age of other siblings.       
 
Parent Volunteers
There are volunteer opportunities within the Hebrew School.
Would you be interested in volunteering for:
  Lag B'Omer   Hebrew Reading Room Assistant
  Chanukah   Shabbat Dinner
  Purim   End-of-Year Celebration
  Other    
Enrollment Agreement

FIELD TRIP PERMISSION
I give my child(ren) permission to participate in field trips planned for Chabad Hebrew School. School vehicles, teachers, or parents’ vehicles will be used, with the proper supervision of teachers and parents.
RELEASE OF INFORMATION AND PHOTOGRAPHS
I give permission for my child(ren)'s picture to be used for internal PR mailing and website where name is not given.
By submitting and initialing this form, parents accept the terms outlined above.  both parents must initial
Medical Emergencies
I authorize the director or director's designee to seek appropriate medical care for my child/ren, if necessary
A.  In case of emergency, when neither parent can be reached, give names of two people who will take responsibility for your child
Emergency Contact 1   Emergency Contact 2  
Name   Name  
Home Phone   Home Phone  
Cell Phone   Cell Phone  
Address   Address  
Town   Town  
Relationship to Student   Relationship to Student  
B.  If parents cannot be reached and emergency medical advice is needed, permission is given to the Chabad staff to phone my child's doctor
Doctor   Phone  
Address   Town  
Hospital Affiliation      
C.  In case of medical emergency requiring immediate emergency care, I authorize the paramedics to take my child to the nearest hospital if necessary.  It is understood that I will hold Chabad harmless for the nature and outcome of any emergency medical treatment.  It is also understood that I leave the decision of what constitutes an emergency to the sole direction of the staff.
 
Mother's Initials   Date  
Father's Initials   Date  
 
   

Chabad Community Hebrew School