Child InformationEnrollment Period of September 2022 - June 2023Child's Name*First NameLast NameChild's Hebrew NameGender*FemaleMaleBirth Date*1 - January2 - February3 - March4 - April5 - May6 - June7 - July8 - August9 - September10 - October11 - November12 - DecemberMonth12345678910111213141516171819202122232425262728293031Day2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920YearHome Address*Street AddressStreet Address Line 2CityState / ProvincePostal / Zip CodePlease SelectUnited StatesAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanThe BahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChilePeople's Republic of ChinaRepublic of ChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCook IslandsCosta RicaCote d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonThe GambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern MarianaNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint BarthelemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSomalilandSouth AfricaSouth OssetiaSpainSri LankaSudanSurinameSvalbardSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTristan da CunhaTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamBritish Virgin IslandsUS Virgin IslandsWallis and FutunaWestern SaharaYemenZambiaZimbabweOtherCountryHome Phone*Siblings Names, Ages and Current SchoolsParent InfomationParent 1 Name*Parent 1 E-mail*Parent 1 Home Phone*if same as child write n/aParent 1 Address*If same as child write N/AParent 1 Cell*Parent 1 Employer*if not applicable, must write n/aParent 1 Business Address*if not applicable, must write N/AParent 1 Business Phone*if not applicable, must write n/aParent 2 Name*Parent 2 E-mail*Parent 2 Home Phone*if same as child write n/aParent 2 Address*If same as child write N/AParent 2 Cell*Parent 2 Employer*if not applicable, must write n/aParent 2 Business Phone*if not applicable, must write n/aParent 2 Business Address*if not applicable, must write N/AGeneral InformationPersons 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 3Allergies*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 herePreferred 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 hereI 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 hereI 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 hereParent E-Signature*Date*MonthDayYear Desired ProgramAvailable ProgramsToddler 2 Days: T, HToddler 3 Days: M, W, FToddler 5 Days: M-FTwo's 3 Days: M, W, FThree's 5 Days: M-FPre-K 5 Days: M-FTamim Kindergarten 5 Days: M-FTamim 1st Grade 5 Days: M-FWaitlisted ProgramsTwo's 2 Days: T, HTwo's 5 Days: M-FTwo's Optional Lunch Program12-1pm | $450 per dayMondayTuesdayWednesdayThursdayFridayThree's & Pre-K Optional Clubs1-2pm | $700 per dayMondayTuesdayWednesdayThursdayFull Day/Full Year CoverageI am interested in learning more about Chabad's Full Day / Full Year Coverage. Please contact me with details.PaymentDeposit Due at Registration$0.00A 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. PaymentCredit Card Check Credit CardVisaMasterCardAmerican ExpressDiscoverCredit Card TypeCredit Card NumberSecurity CodeName on Card1 - January2 - February3 - March4 - April5 - May6 - June7 - July8 - August9 - September10 - October11 - November12 - DecemberExpiration Month2022202320242025202620272028202920302031Expiration YearPlease mail check to: Chabad Preschool 75 Mason Street Greenwich, CT 06830Should be Empty: Submit This page uses TLS encryption to keep your data secure.