Preschool & Tamim Academy Registration 2022/23

Child Information
Enrollment Period of September 2022 - June 2023
Child's Name*

First Name Last Name
Child's Hebrew Name
Gender*
Birth Date*

Month Day Year

Home Address*

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

Home Phone*
Siblings Names, Ages and Current Schools
Parent Infomation
Parent 1 Name*
Parent 1 E-mail*
Parent 1 Home Phone*

if same as child write n/a
Parent 1 Address* If same as child write N/A
Parent 1 Cell*
Parent 1 Employer*

if not applicable, must write n/a
Parent 1 Business Address* if not applicable, must write N/A
Parent 1 Business Phone*

if not applicable, must write n/a
Parent 2 Name*
Parent 2 E-mail*
Parent 2 Home Phone*

if same as child write n/a
Parent 2 Address* If same as child write N/A
Parent 2 Cell*
Parent 2 Employer*

if not applicable, must write n/a
Parent 2 Business Phone*

if not applicable, must write n/a
Parent 2 Business Address* if not applicable, must write N/A
General Information
Persons permitted to remove the child from Preschool on behalf of the parent:
Authorized Person 1*
Authorized Person 2*
Unauthorized Person(s)
Provide the name of at least one NON PARENT to be contacted in the case of an emergency.
Emergency Contact 1*
Emergency Contact 2*
Emergency Contact 3
Allergies*
Penicillin Allergy*
Anti-Tetanus*
Child's Physician*
Physician's Phone*
Physician's Address*
Child's Dentist*
Dentist's Phone*
Dentist's Address*
I give my consent for the First Aid and CPR certified staff of Chabad Preschool to administer first aid and 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.

Initial here
Preferred Medical Facility*
I acknowledge that I have read the Parent Handbook and agree to abide by the policies contained in it and that the techniques used to manage child behaviors in the facility have been discussed with me prior to enrollment. I understand that I can speak witht he preschool director at any time with questions or concerns about the behavior policy.

Initial here
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 trip away from our facilities.

Initial here
I hereby give permission for my child to be photographed or video taped during school. Such photos and videos may be used for advertising and promotions.

Initial here
Parent E-Signature*
Date*

Month Day Year
Desired Program
Available Programs

Toddler 2 Days: T, H Toddler 3 Days: M, W, F Toddler 5 Days: M-F Two's 3 Days: M, W, F Three's 5 Days: M-F Pre-K 5 Days: M-F Tamim Kindergarten 5 Days: M-F Tamim 1st Grade 5 Days: M-F
Waitlisted Programs

Two's 2 Days: T, H Two's 5 Days: M-F
Two's Optional Lunch Program 12-1pm | $450 per day

Monday Tuesday Wednesday Thursday Friday
Three's & Pre-K Optional Clubs 1-2pm | $700 per day

Monday Tuesday Wednesday Thursday
Full Day/Full Year Coverage

I am interested in learning more about Chabad's Full Day / Full Year Coverage. Please contact me with details.
Payment
Deposit Due at Registration

$0.00
A deposit of $1500 per child is due at the time of registration. Please note that full payment is due by July 1, 2022 . Check or credit card payments are accepted.

Payment

Credit Card Check

Should be Empty:

This page uses TLS encryption to keep your data secure.

Child Information

Parent Infomation

General Information

Desired Program

Payment