Chabad Hebrew School Logo

REGISTRATION FORM

Name: Child #1 ____________________________  

Hebrew Name _______________________

Child #2_____________________________

Hebrew Name _______________________

Child #3_____________________________

 Hebrew Name _______________________

(Current Age and Grade Entering ):
 

Child #1: Date of Birth ________/______/______ Grade _____

Child #2: Date of Birth ________/______/______ Grade _____

Child #3: Date of Birth ________/______/______ Grade _____

Family Information:

Father’s Name _________________________

Hebrew Name _________________________

Address ______________________________

City ______________ ST _____ ZIP _______

Phone: Home ___________ Work _________

Email:________________________________

Occupation: ___________________________

 

Mother’s Name ______________________

Hebrew Name _______________________

Address ____________________________

City ______________ ST _____ ZIP _____

Phone: Home _________ Work __________

Email:_______________________________

Occupation: __________________________

 

Were there any conversions or adoptions in your family? _____________

Explain _______________________________________________________________________

Are the birth parents of the child/ren Jewish? Mother _____ Father _________

Medical Info:

______________________________________________________________________________

Does your child have any learning difficulties with general studies?

______________________________________________________________________________

Emergency Contact: Name __________________

Phone: ___________ Relation ____________

Is there any special medical or other information regarding your child, which our school should be aware of? (if more space is needed please use other side) __________________

I hereby permit my child/ren to participate in all school activities and join in school trips on and beyond school properties. In case of emergency, I hereby authorize the school to have my child/ren taken care of by a physician in any way the situation may call for.

Parent’s Signature ____________________________________ 

Date _____________________

[] I would be willing to help in school activities

[] I would be willing to assist in fundraising activities

[] Please do not include me in the school directory

 

Please print and mail to:

Chabad of Reston - Herndon

11654 Plaza America Drive # 775

Reston VA 20190