Child's Information
First Name
Last Name
Hebrew Name
Grade 2021-22
Day Signing Up For Sunday
Hebrew Reading Proficiency None Well Fair  Poor
Hebrew Speaking Proficiency None Well Fair  Poor
Previous Jewish Education? Yes No
Parent Information
All information is confidential.
Father's Name
Father's Hebrew Name
Father is Jewish  By birth  By conversion  Not Jewish
Father's Cell/Work Phone
Father's Work Address
Mother's Name
Mother's Hebrew Name
Mother is Jewish  By birth  By conversion  Not Jewish
Mother's Cell/Work Phone
Mother's Work Address
Home Address
Postal Code
Home Phone
Email Address
If either parents converted, where was the conversion performed?
Synagogue Affiliation if any
Emergency Information
Emergency Contact 1
Emergency Contact 2

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.

Vaccinations Current Yes No
Date of last tetanus shot

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.

I Accept

Name: Initials:


We look forward to a wonderful year of learning and growth!