Hebrew School & Teens Regis tra tion for 2016-2017

STUDENT INFORMATION

First Name Last Name
Hebrew Name D.O.B.
School Grade Entering
Hebrew Reading Proficiency None Somewhat Well
Previous Jewish Education Yes No If yes - where?


PARENT INFORMATION

Father's Name Father's Cell
Mother's Name Mother's Cell
Address City, State, Zip
Home Phone Email
Were there any conversions or adoptions in the family? Yes No
If yes, please explain:

EMERGENCY INFORMATION

Emergency Contact 1 Phone
Emergency Contact 2 Phone

CONFIDENTIAL: Does your child have any allergies or other medical condition we should be aware of? If yes, please describe them and indicate special precautions or care needed.


As the parent(s) or legal guardian of the above child, I/we authorize any adult acting on behalf of Chabad Hebrew School to hospitalize or secure treatment for my child, I further agree to pay all charges for that care and/or treatment. It is understood that if time and circumstances reasonably permit, Chabad Hebrew School personnel will try, but are not required, to communicate with me prior to such treatment. I hereby give permission for my child to participate in all school activities, join in class and school trips on and beyond school properties and allow my child to be photographed while participating in Chabad Hebrew School activities and that these pictures may be used for marketing purposes.

BY SIGNING MY NAME AND INITIALS BELOW YOU ARE ACCEPTING ALL THE ABOVE

NAME: INITIALS:

For Payment click here

For more info please Email Esty@ChabadLeawood.com or Call 913-228-2770 Ext. 3