Registration Form  (Calendar will be mailed upon receipt of registration forms.)
Name of Child:    Age:
Hebrew Name:   Birth date: 
Home Address:
Other Parent Address (if different):
Telephone:   Work:
Cell:    E-mail:
Previous Hebrew School      

Name of Day School: 

  Grade:
         
Mother's Hebrew/English Name:     Is the natural mother Jewish by birth? yes no
Father's Hebrew/English Name:     Is the natural father Jewish by birth? yes no
Are all grandparents Jewish by birth?  yes no      
Has there been a conversion or adoption in the family or extended family? If yes, please specify:  
Synagogue with which family is affiliated:    
Referred by:    
 
As the parent(s) or legal guardian of the above child, I/we authorize any adult acting on behalf of the Chabad of Scottsdale Hebrew School to hospitalize or secure treatment for my child, I further agree to pay all charges for that care and/or treatment. It is understood that if time and circumstances reasonably permit, the Chabad of Scottsdale Hebrew School personnel will try, but are not required, to communicate with me prior to such treatment. 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 the Chabad of Scottsdale Hebrew School activities and that these pictures may be used for marketing purposes.
I Accept   Name: 

 I (we) hereby permit my child to participate in all school activities, join in class and school trips on and beyond school properties.

Initials:

 

Medical and Developmental Form
Does your child have any medical, developmental or behavioral issue that we should know about? Describe:
 
Please list any medication your child is taking on a regular basis:
 
Does your child have any allergies towards food or medication?


Does your child have need for an epi-pen? 

 Yes  No
If yes, please provide a current epi-pen and written permission to administer to Hebrew School at the beginning of the school year
         
Medical Emergencies
I authorize the director or director's designee to seek appropriate medical care for my child, if necessary.

A. In case of emergency, when neither parent can be reached, give names of two people who will take responsibility for your child:

Emergency Contact 1     Emergency Contact 2  
Name

  Name

Home Phone   Home Phone
Business Phone
  Business Phone
Address   Address
City   City
Relationship to Student   Relationship to Student
B. If parents cannot be reached and emergency medical advice is needed, permission is given to the Hebrew School staff to phone my child's doctor:
Doctor   Phone
Address   City
Hospital Affiliation      
C. In case of medical emergency requiring immediate emergency care, I authorize the paramedics to take my child to the nearest hospital if necessary. It is understood that I will hold BFHS harmless for the nature and outcome of any emergency medical treatment. It is also understood that I leave the decision of what constitutes an emergency to the sole direction of the staff (please sign)
Mother's Initials   Date
Father's Initials   Date

 

PAYMENT  Please note: Applications will not be processed without payment and a listed CC number

Cost: 

$750 for members

$950 for non-members 


 
Please charge my credit card

Charge full payment:

 $ 

 

 Bill me monthly through Dec. 2018
  $  

         
CC Type   Card Number  
Billing Address   City, State, Zip
Charge Amount   ExpDate
CVV
 
We look forward to a wonderful year of learning and growth!

For questions, call 480-998-1410 or email  Dina@chabadofscottsdale.org