Religious School Registration Form

Downloadable forms

Part I: Student Information
Last Name First Name
Hebrew Name    
Age Birthday
Grade Entering School
Last Name First Name
Hebrew Name    
Age Birthday
Grade Entering          School
Part II: Parents' Information
Father's Name Hebrew Name
Father's Email Phone
Occupation    
Mother's Name Hebrew Name
Occupation Phone
Occupation    
Email (parent) Synagogue Affiliation
Father Cell Mother Cell
Part III: Religious & Educational History
Previous Hebrew Education
   
 
Part IV: Medical Information (confidential)
Up to date with vaccinations Yes No  
Any special medical or other information, which we should be aware of including allergies?
Part V: Program
Hebrew School Private Tutoring
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 Phone
Relationship to Child City/Town
Family Physician Phone
Medical Insurance Co Policy Number
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.
       
Name of Parent Date
Credit Card Information:
Name on Card  
Credit Card Number
CVV

monthly amount in the box above:
Please charge the above amount to my credit card each month for the next ten months.