Student Information
First Name *
Last Name *
Jewish Name
Gender * Male Female
Date of Birth *
Allergies? *

Yes No

Is there anything else we should know about your child?
Parent Information
Father Mother
Title * Mr. Dr. Title *

Mrs. Ms.

Dr.

Name *
Name *
Home Phone *
Home Phone *
Cell Phone *
Cell Phone *
Work Phone
Work Phone
Email *
Email *
Occupation
Occupation
Home Address *
Home Address *
City *
City *
Province *
Province *
Postal Code *
Postal Code *

Is the father Jewish? *


Is the mother Jewish? *
Have there been any conversions or adoptions in the family (please specify)? *
Emergency Contact Information
Emergency Contact 1 Emergency Contact 2
Name *
Name *
Relationship to Child *
Relationship to Child *
Home Phone *
Home Phone *
Cell Phone *
Cell Phone *
Child's Medicare Number *

Terms of Registration
Terms
*Enrolment in Chabad Hebrew School is not a confirmation of the student's Jewish status.
Date *
Signature *