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Application

Application

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BH"

Chabad of Orange / Woodbridge Hebrew School

Application – 2014-2015 / 5775

 

Student Information

 

First child: ___________________________________________ Hebrew name: __________________________

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

Does your child read basic Hebrew?   __Yes __No    If yes: __Good __Fair __Poor

 

Second child: _________________________________________ Hebrew name: __________________________

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

Does your child read basic Hebrew?  __Yes  __No     If yes: __Good __Fair__Poor

 

Third child: __________________________________________ Hebrew name: __________________________

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

 

Does your child read basic Hebrew? __Yes  __No     If yes: __Good __Fair__Poor

Were there any conversions or adoptions in your family? __Yes   __No    

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 ____________________________

 

Street Address:_______________________________________________________

City, State, Zip: ______________________________________________________________________________

Emergency Information

 

Emergency Contact: ____________________ Home Phone: ____________________

Work Phone: _________________ Cell 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: Blumah Hecht
                                                                                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 ( info@chabadow.org). 

 

 

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