Please note: Your child is not registered in the Chabad Hebrew School until you receive a confirmation phone call or email.

Childs Name *

First

Last

Hebrew Name *

Date of Birth *

Current School

School Year Level *

Previous Jewish Education (if yes where?)

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Parent Information

Father's Name *

First

Last

Father's Cell

Mother's Name *

First

Last

Mother's Cell

Is the natural mother of the child Jewish? *

Have there been any conversions or adoptions in the family? *

If yes, please explain

Emergency Information

Emergency Contact Name *

First

Last

Phone / Cell *

Relationship to Child

Is your child taking permanent medications? *

Any known allergies (incl. reactions to medications) and any present medical conditions? *

CONFIDENTIAL: Please list all allergies

Digital Signature of Parent or Legal Guardian

Date