Student information

Which School does your child attend?

Grade entering this fall:

Synagogue

affiliation if any:

Previous Hebrew Education: Does your child read basic Hebrew?

Does your child speak Hebrew?

Does your child have any difficulties with his general studies?

if yes please specify

Is the biological Father Jewish?

Is the biological Mother Jewish?*

Where there any conversions or adoptions on the mothers side of the family?*

if yes please explain

*CHS welcomes every child, regardless of one's religious background or level of observance. CHS does not require membership or prior affiliations as a condition for enrollment. Acceptance to Hebrew School does not validate in anyway you or your child's Judaism. The process of being Bar and Bat Mitzvah through Chabad will require proof of mothers Judaism based on the guidlines of the Rabbinical court.

Parent information

MOTHERS INFO:

Mothers Email

Mothers Occupation

Mothers

Cell-Phone Number

Mothers

Work Phone Number

Mothers

Work Address

FATHERS INFO:

Fathers Email

Fathers

Occupation

Fathers

Cell-Phone Number

Fathers

Work Phone Number

Fathers

Work Address

Medical information

Doctors Name

Doctors Phone Number

Doctors Address

Medical Coverage/ Insurance Company

Policy Number

Allergies

(if any please list)

Medical Conditions:

If any please explain

Up to date with vaccinations?

Date of last tetanus shot

Emergency Contact

Emergency Contact #1

Emergency Contact #1 Home Phone

Emergency Contact #1 Cell Phone

Emergency Contact #2

Emergency Contact #2 Home Phone

Emergency Contact #2 Cell Phone

Permissions

Permission for Emergency Medical Treatment:

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As the parent(s) or legal guardian(s) I/we authorize any adult acting on behalf of the Chabad Hebrew School of Greater Gainesville & Manassas to hospitalize or secure treatment for my child. I further agree to pay for all charges for that care and/or treatment. It is understood that, if time and circumstances reasonably permit, Chabad Hebrew School will try to communicate with me prior to such treatment.

Parent Signature

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 while participating in Chabad Hebrew School activities and that these pictures may be used for marketing purposes.

Submit

Please note all fields in this form are required, please write "NA" or "000" in fields that are not applicable.