Registration

Parent 1's Name*

First Name Last Name

Parent 2's Name*

First Name Last Name

Check which apply:*

Mother born JewishMother converted

Parent 1's E-mail*

Parent 2's E-mail*

Home Phone*

Area Code Phone Number

Parent 1's Cell*

Area Code Phone Number

Parent 2's Cell*

Area Code Phone Number

Parent 1's Work phone

Area Code Phone Number

Parent 2's Work phone

Area Code Phone Number

Parent 1 Address*

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Parent 2 Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Yes, I can volunteer! I can help with the following:

Child 1 Name*

First Name Last Name

Child 1 Hebrew Name:*

Child 1 Birth Date*

Month Day Year

Help us figure out the Hebrew birthday!*

born during the dayborn in the eveningborn at dusk/sunset

Child 2 Name

First Name Last Name

Child 2 Hebrew Name:

Child 2 Birth Date

Month Day Year

Help us figure out the Hebrew birthday!

born during the dayborn in the eveningborn at dusk/sunset

Child’s Physician

Physician’s Telephone

Physician’s Office Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Insurance Company Covering the Child(ren)

Policy Number Child 1:

Policy Number Child 2:

Expiration Date

Please list below any psychological or medical conditions,medications currently being taken ,dietary requirements,allergies (include allergies to medications) etc pertaining to your child.

1. Name*

1. Relationship to child(ren)*

1. Cell Phone*

2. Name*

2. Relationship to child(ren)*

2. Cell Phone*

(Electronic) Signature of Parent. *

Date (MM/DD/YY*

I hereby give permission,in the event of an emergency, for the Director or the
Teacher at North Shore Community Hebrew School to take whatever steps
maybe necessary for the medical care of my child(ren).
I understand that in order for the North Shore Community Hebrew School
to assume responsibility for my child,I or the persons whom I have designated
to pick up my child in an emergency.I understand that unless there is a need for
immediate action, the order of the steps taken will follow,but will not be limited
to, the outline below:

1.The parent/ guardian will be called.
2.Note: If the parent/guardian is unavailable,the emergency contact person
designated by the parent/guardian will be called.
3.Child’s physician will be called.
4.If these efforts are unsuccessful the following steps will be taken(order may vary
depending on the situation):
I. Another physician will be called.
II.The child will be taken to the nearest emergency room accompanied by a staff
member.
III An ambulance will be called to take the child to the nearest emergency room
accompanied by a staff member.

I give consent to any emergency facility and physician to administer any necessary
medical treatment to my child as the situation may warrant it.

Parent/Guardian’s Signature*

Date*

Transport/Emergency Care as listed above*

I give permissionI don't give permission

Initial Here:*

I give permission to North Suburban Lubavitch Chabad - Central Avenue Synagogue, 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 North Suburban Lubavitch Chabad - Central Avenue Synagogue.

Media Authorization*

I give permissionI don't give permissionI allow with the exception of Facebook.

Initial Here:*

Authorized to pick up

Emergency ContactParentsOther

Other Pick up:

Pick up's Number

Area Code Phone Number

Registration:

One Child - $775 + $125Two Children -$1,550 + $250One Child - CTeen Jr - $400

Total to be charged today:*

$

Total

$0.00

Payment

Credit Card Check

Postal / Zip Code

Country

Tuition:

Parents Information

Child's Information

Medical Information

Emergency Contacts:

Permission forms

Book & Activity Fee

Payment