BH

ChabadHebrew SchoolApplication – 2009-2010 / 5770

Student Information

First child: ___________________________________________ Hebrew name: __________________________

Birth date: ______ / ______ / ______ Entering grade: ____ School: _____________________________________

Does your child read basic Hebrew?   qYes   qNo     If yes:    qGood     qFair     qPoor

Second child: _________________________________________ Hebrew name: __________________________

Birth date: ______ / ______ / ______ Entering grade: ____ School: _____________________________________

Does your child read basic Hebrew?   qYes   qNo     If yes:    qGood     qFair     qPoor

Third child: __________________________________________ Hebrew name: __________________________

Birth date: ______ / ______ / ______ Entering grade: ____ School: _____________________________________

Does your child read basic Hebrew?   qYes   qNo     If yes:    qGood     qFair     qPoor

Were there any conversions or adoptions in your family? qYes   qNo     If yes, please explain: _____________ ______________________________________________________________________________________

Additional comments: ______________________________________________________________________________________

Parent information

Father’s name: ___________________________________________ Home phone: ________________________

Work phone: _____________________________________________ Cell phone: _________________________

Occupation: ______________________________________________ E-mail ____________________________

Mother’s name: ___________________________________________ Home phone: _______________________

Work phone: _____________________________________________ Cell phone: _________________________

Occupation: ______________________________________________ E-mail ____________________________

Address:______________________________________________________________________________

City, State, Zip: ______________________________________________________________________________

Emergency Information

Emergency Contact: _________________________________________ Home Phone: _____________________

Work Phone: ______________________________________________ Mobile Phone: _____________________           

Doctor: __________ Phone Number: _____________________ Address: ________________________________

Allergies or other Medical Condition: ____________________________________________________________

________________________________________________________________________________

* * *

As the parent(s) or legal guardian of ___________________________________, 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 attend all field trips and outings sponsored by Chabad Hebrew School.

___________________________________________          _______________________

Signature of parent or legal guardian                                                               Date

* * *

Please mail completed form with a $100.00 deposit per child to:

                                                                              Chabad Hebrew School

                                                                              ATTN: Perel Hodakov

261 Derby Avenue

Orange, CT 06477

Checks should be made payable to Chabad Hebrew School. Please feel free to contact me with any questions regarding the program or payment. I can be reached at 389-8472 or Chabadhs@yahoo.com. Hebrew School starts on Sunday, September ,13th. Please be sure to have your registration and payment in order.