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

Health Card Number in case of emergency (optional) 

*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).