Student Application Form
Print Application
Child's Information
*Last Name
*First Name
*Hebrew Name
*Date of Birth
*Address
*City
*Postal Code
*Home Telephone
Is there any special information we should know about your child? (If yes, please elaborate.)
Has your child attended Hebrew School before? Yes No
If yes, which one?
*Current School
*Current Grade
If there is more than one class for my child's grade, I would like my child to be with the following friends
Father's Information
*Name
*Cell Phone
*E-mail Address
*Occupation
Company Name
Company Address
Company Phone
Mother's Information
*Name
*Cell Phone
*E-mail Address
Occupation
Company Name
Company Address
Company Phone
General Information
Have there been any conversions in the family? Yes No
If yes, please elaborate
Was this child born to a Jewish mother? (Jewish Law mandates that we ask this question.) Yes No
Are you a member of a Synagogue? Yes No
If yes, which one?
Names and ages of other siblings
Medical Information
*Pediatrician Name
*Pediatrician Telephone
*Pediatrician Address
Allergies or medical conditions
In case of emergency, contact (other than parent)
Emergency Contact #1
*Name
*Address
*Relationship to Child
*Telephone
Cell
Emergency Contact #2
*Name
*Address
*Relationship to Child
*Telephone
Cell
How did you hear about us? If you were referred to us by someone, please specify from whom you were referred.
Payment Information
I will be paying Full Tuition Partial Tuition in the amount of
$
The rest will be paid by:
Additional Payee Information
Name
Address
Tel Cell
Amount Paying $
Please send payment cheques to Chabad Romano Centre, 10500 Bathurst St., Maple, ON L6A 0H2 or pay via credit card by clicking here .
Important
Please print, sign and send the "
Permission to Receive Emergency Care " declaration. In addition, please send a non-refundable deposit (to be deducted from the total fee).
ALEPH CHAMP