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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).