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Registration 2017

Registration 2017

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REGISTRATION 2017-2018

Child Information
Child's Last Name
Child's First Name
  Hebrew Name
Gender
DOB (mm/dd/yy)
  Home Phone
Address
City, State, Zip
   
       
Sibling 1 Name
Age
  School Attending
Sibling 2 Name
Age
  School Attending
       
Parent Information
Mother
Mother's Name
Hebrew Name
  Occupation
Phone
Cell 
  Business Phone

Address

Business Address
  Email



  Jewish by:
Birth Choice
Father
Father's Name
Hebrew Name
  Occupation
Phone
Cell
  Business Phone
Address
Business Address
  Email


    Jewish by:
Birth Choice
Synagogue of family’s affiliation:
General Information
Emergency Contacts: Name / Relationship / Phone #
Are any medications given regularly?
Any known allergies? Yes No If so, please explain:
Any food restrictions?
Child's Physician
Phone
Address
Child's Dentist
Phone
Address
I hereby permit my child to participate in field trips of Chabad Preschool. (I understand that as a rule I will receive notice of any trips and each trip will require individual permission.)
I hereby give permission for my child to be photographed or videoed as part of his/her and other children’s enrichment and enjoyment, and for possible use in advertising and promotion
 I have a Parent Handbook and understand the school behavior policy is outlined within it. I understand I can speak with the Preschool Director at anytime with questions or concerns about the behavior policy.
Parent's Signature Date
Desired program Lunch Extended Day Days of the Week
Two yr. old (Aleph)
Morning: 9-12pm
M T W R F N/A 2 Days: T,R
3 Days: M,W,F
5 Days: M-F
Three yr. old (Bet)
Day 9-12pm
M T W R F M T W R
Four yr. old (Gimmel)
Day: 9-1pm
All 4s Stay for Lunch 5 Days M T W R N/A
Payment Information      
I will send a Check Charge my card below 

Note: Full payment, including lunch and extended is due June 30th and is considered non refundable. To complete your child's registration please submit a $1500 deposit at this time.
Total Amount
First Name
Card Type
Last Name
Card Number
Address
Exp. Date
City
CVV Code
State
Zip

 

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