Information

Child's Information

Child's First Name *

Child's Last Name *

Please be sure to write your FULL street address and apartment number if applicable

Street Address *

Supplemental Address

City *

State *

Connecticut State *

Postal Code *

Country *

United States Country *

Gender *

Female Male

Hebrew Name

Example: David or דוד

Child's Birth Date *

Birth Date Before Sunset

Yes

No

Unknown

Grade Entering *

Child's School *

Hebrew Reading Proficiency *

None Somewhat Well

Previous Jewish Education *

Father`s Name (first and last) *

Father's Hebrew Name

Jewish By

Birth Choice

Mother's Name (first and last) *

Mother's Hebrew Name

Jewish By

Birth Choice

Were there any adoptions or conversions in the family?

Emergency Contact 1 *

Emergency Contact 1 Phone *

Emergency Contact 2

Emergency Contact 2 Phone

CONFIDENTIAL: Does your child have any allergies or other medical condition we should be aware of? If yes, please describe them and indicate special precautions or care needed. *

As the parent(s) or legal guardian of the above child, I/we authorize any adult acting on behalf of Chabad P.O.G.S. to hospitalize or secure treatment for my child, I further agree to pay all charges for that care and/or treatment. It is understood that if time and circumstances reasonably permit, Chabad P.O.G.S. personnel will try, but are not required, to communicate with me prior to such treatment. I hereby give permission for my child to participate in all school activities, join in class and school trips on and beyond school properties and allow my child to be photographed while participating in Chabad P.O.G.S. activities and that these pictures may be used for marketing purposes. By submitting this form I acknowledge and agree to the terms and conditions

I Accept *

.

Name

Initial *

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CHABAD OF STAMFORD - JEWISH CENTER FOR LIFE AND LEARNING