Printed from ChabadofLaMorinda.com

Register

Registration for year 2017-2018 is now open!
Please fill out this form as an initial registration for the Chabad Hebrew School.
Confirmation of acceptance will be acknowledged only after this registration form is reviewed and an acceptance letter is received.
To Print Hebrew School Application Form Click Here
Student Information
First Name*
Last Name*
Hebrew Name
Date of Birth*
MonthDayYear
Age
MaleFemale
Does your child have any previous Jewish Education
YesNo
If yes, please describe
What school does your child attend?
Grade entering:
Is the natural father of the child Jewish?
YesNo
Is the natural mother of the child Jewish?
YesNo
Were there any conversions or adoptions in your family?
YesNo
If yes, please describe
Any considerations, such as learning disorder or difficulty, the school should be aware of? (Confidential):
Parents Information
Father's Name
Cell Number
Email
Mother's Name
Cell Number
Email

Address

Emergency Contact Information
Emergency Contact 1
Cell Number
Relationship to child
Emergency Contact 2
Cell Number
Relationship to child
Child's physician or medical facility
Physician's phone
Physician's address
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 trip on and beyond school properties and allow my child to be photographed while participating in Chabad Hebrew School activities.
*
AcceptDo not accept
Initial here:
Registration fee
$36
Total
$0.00

Payment

Credit Card

Billing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

This page uses TLS encryption to keep your data secure.

Student Information