Enrollment Form

Chabad Hebrew School 2018-2019

 

Student Information

Child's First and Last Name  

Hebrew Name:

Date of Birth:

Address:

City, State and Zip:

Home Phone:

Grade School Year 2018-2019:

Additional Comments:


 

Parent or Guardian's Name:

Cell Phone:

Email:

Doctor's Name:

Doctor's Address:

Doctor's Phone:

Allergies:

Medical Conditions:

Other Important Information:


Please list two emergency contacts:

Name/Phone/Relationship:

 

Name/Phone/Relationship:

P ERMISSION FOR E MERGENCY M EDICAL T REATMENT :

As the parent(s) or legal guardian of , I/we authorize any adult acting on behalf of Chabad of Armonk, Chappaqua and Pleasantville 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.

Initials of Parent or Legal Guardian