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REGISTRATION 2019-2020

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
Mother's Employer**
 
Home Phone* 
Business Phone** 
 Cell Phone

Address*

Business Address**
Email
*only if different then student, if same write n/a **if not applicable write N/A

Father
Father's Name
Father's Employer**


Home Phone* 
Business Phone**
Cell
Address*
Business Address**
Email
*only if different then student, if same write n/a
 **if not applicable write N/A  
 
General Information
Persons permitted to remove the child from Preschool on behalf of the parent:
Name / Relationship / Phone #
Please note if there is anyone specifically NOT allowed to remove your child from school:
Emergency Contacts: 
Name / Relationship / Phone #
List any allergies and specify degree of severity:
Is child allergic to penicillin or any other drug that may need administration at the hospital?   If yes, please describe:
When did child last receive anti-tetanus injection?
Child's Physician
Phone 

 
Address

Child's Dentist 
Phone 
Address

 I give my consent for the First Aid and CPR certified staff of Chabad Preschool to administer first aid and B”H CPR to my child and to contact the above named physician or dentist if my child has a medical emergency. I also give my consent for my child to be transported to the nearest hospital in the event of a medical emergency. I will be responsible for all medical fees.
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 Clubs (1-2 pm) Days of the Week
 Toddlers 
Morning: 9-12pm
N/A N/A

 2 Days: T,R 
 3 Days: T,W,R 
 5 Days M-F

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 9-1pm
All 3's stay for lunch 5 days M T W
 R  F
N/A
Four yr. old (Gimmel)
Day: 9-1pm
All 4s stay for lunch 5 days M T W
 F

N/A

Payment Information    
I will send a Check Charge my card below 

Note: $1500 deposit per child and PTA dues ($155 for 1 child, $205 for 2+ children) are due at time of registration.  Full payment is due May 1, 2019 and is considered non refundable.  
Total Amount
First Name
Card Type
Last Name
Card Number
Address
Exp. Date
City
CVV Code
State
Zip