Part I: Student Information |
Last Name |
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First Name |
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Hebrew Name
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Age |
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Birthday |
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Grade Entering
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School |
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Last Name |
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First Name |
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Hebrew Name |
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Age |
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Birthday |
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Grade Entering |
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School |
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Part II: Parents' Information |
Father's Name |
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Hebrew Name |
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Father's Email
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Phone |
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Occupation |
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Mother's Name |
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Hebrew Name |
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Occupation |
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Phone |
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Occupation |
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Email (parent) |
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Synagogue Affiliation |
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Father Cell |
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Mother Cell |
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Part III: Religious & Educational History |
Previous Hebrew Education |
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Part IV: Medical Information (confidential) |
Up to date with vaccinations |
Yes No |
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Any special medical or other information, which we should be aware of including allergies? |
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Part V: Program |
Hebrew School |
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Private Tutoring |
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I hereby permit my child to participate in all school activities, and to join in class and school trips on and beyond school properties and use any transportation selected by the Congregation Chevra Thilim Hebrew School. |
Emergency Contact Information |
Person to be contacted in case of an emergency when parents cannot be reached: |
Name |
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Phone |
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Relationship to Child |
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City/Town |
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Family Physician |
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Phone |
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Medical Insurance Co |
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Policy Number |
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Medical Release Form: |
I hereby give consent to the administration of the Congregation Chevra Thilim Hebrew School to take whatever medical measures they deem necessary, at my expense, for my child in the event of a medical emergency. |
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Name of Parent |
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Date |
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Credit Card Information: |
Name on Card
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Credit Card Number |
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CVV |
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monthly amount in the box above:
Please charge the above amount to my credit card each month for the next ten months.
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