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ב"ה

Little Scholars

Scroll down to Register.
STUDENT INFORMATION
Child's Name*

First Name Last Name
Hebrew Name*
Birth Date*

Month Day Year
School*
Previous Preschool*
Grade entering*
Is the natural mother of the child Jewish?*

Yes No
Were there any conversions or adoptions in your family?*

Yes No
If yes, please describe.
Additional notable Information
PARENTS INFORMATION
Father's Name*

First Name Last Name
Home Phone Number

Area Code Phone Number
Work Phone Number

Area Code Phone Number
Father Cell

Area Code Phone Number
Occupation
Mother's Name*

First Name Last Name
Work Phone Number

Area Code Phone Number
Mother Cell

Area Code Phone Number
Occupation
E-mail*

Address*

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

EMERGENCY INFORMATION
Emergency Contact*

First Name Last Name
Phone Number*

Area Code Phone Number
Work Phone Number

Area Code Phone Number
Cell Number*

Area Code Phone Number
Doctor

First Name Last Name

Doctor's Address

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

Doctor's Phone Number

Area Code Phone 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:*

Month Day Year
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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