Friendship Circle Hebrew School Registration Form

CHILD INFORMATION

Child's First Name Child's Hebrew Name
Child's Family Name
Name Child is Called
Date of Birth Male Female

Additional Information:
Please email us with more information you feel we need to know.


Current Grade Prior Jewish Education
PARENT INFORMATION
Parent 1 Name Parent 2 Name
Parent 1 Cell Parent 2 Cell
Parent 1 Home Phone Parent 2 Home Phone
Parent 1 Work Phone Parent 2 Work Phone
Parent 1 Email Parent 2 Email
Home Address Parent 2 Address
City State Zip City State Zip
This is the child's primary address
Parent Volunteers are always appreciated! Please tell us if you are available to volunteer as a chaperone for local field trips, assist in special programming or have special interests or skills you would like to bring into the classroom.
PICK UP INFORMATION: The following people are authorized to pick up my child.
Name Name
Relationship to Child Relationship to Child
Phone 1 Phone 1
Phone 2 Phone 2
EMERGENCY INFORMATION
Doctor Name Doctor Phone
If parent can not be contacted, the following person may be called in the event of an emergency.
Emergency Contact Name Emergency Contact Phone 1

Relationship to Child

Phone 2
PAYMENT INFORMATION (second child is less 10%)
$1000 for the year (27 classes)


I want to pay in full for the whole year. Charge my card now for $500 and in January 2016 for the 2nd semester for another $500.
Card Type MC Visa Amex Amount to charge $
First Name Last Name
Card Number Expiration Date
Notes:

I hereby give permission for my child to be transported to and from field trips, and to participate in them in all activities. I understand that during the course of the Friendship Circle Hebrew School my child can be hurt. I accept the risk of possible injury and authorize any member of the Chabad of the West Side staff to render any necessary first aid. Furthermore, in an emergency case, I hereby authorize Sarah Alevsky, Rabbi Chayim Alevsky or another staff member to have my child taken care of by a physcian or other medical person in any way the situation calls for.Initial here:

I give permission I do NOT give permission to Chabad of the West Side and the Friendship Circle Hebrew School, and those authorized by Chabad, to take photographs and to make recordings of my children and my family, and to use them in original or modified form in all media now or hereafter known, with or without my name or information about me, for the promotion, public education, and/or fundraising activities of Chabad of the West Side.
Initial Here:

Form