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ב"ה

Little Scholars

Scroll down to Register.
STUDENT INFORMATION
Child's Name*
First NameLast Name
Hebrew Name*
Birth Date*
MonthDayYear
School*
Previous Preschool*
Grade entering*
Is the natural mother of the child Jewish?*
YesNo
Were there any conversions or adoptions in your family?*
YesNo
If yes, please describe.
Additional notable Information
PARENTS INFORMATION
Father's Name*
First NameLast Name
Home Phone Number
Area CodePhone Number
Work Phone Number
Area CodePhone Number
Father Cell
Area CodePhone Number
Occupation
Mother's Name*
First NameLast Name
Work Phone Number
Area CodePhone Number
Mother Cell
Area CodePhone Number
Occupation
E-mail*

Address*

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

EMERGENCY INFORMATION
Emergency Contact*
First NameLast Name
Phone Number*
Area CodePhone Number
Work Phone Number
Area CodePhone Number
Cell Number*
Area CodePhone Number
Doctor
First NameLast Name

Doctor's Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Doctor's Phone Number
Area CodePhone Number
Allergies or other Medical Condition:
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 for publication while participating in Chabad Center Hebrew School activities.
Signature:*
Date:*
MonthDayYear
Additional comments/concerns:
TUITION AGREEMENT
$100 for the year, 8 classes total. Please note: There is a 2.5% surcharge for all credit card payments
Optional Sponsorship
I would like to sponsor tuition for another child to participate in Little Scholars ($100)
Total
$0.00

Payment

Credit Card Check

Postal / Zip Code

Country

CVV:
Should be Empty:

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