Family Info Father's Full Name:* First Name Last Name Father's Email E-mail:* Father's Phone Number:* Is the Father Jewish?:* YesNo Mother's Full Name:* First Name Last Name Mother's E-mail:* Mother's Phone Number:* Is the Mother Jewish?:* YesNo Child's Primary Address:* Street Address Street Address Line 2 City State / Province Postal / 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 SaharaYemenZambiaZimbabweOther Country Marital Status of Parents: SingleMarriedDivorcedWidowedOther Any conversions in the family?: YesNo Child Information How many children are you registering?:* 1234 Child #1 Child #1 Child #1 Child #1 Child #1 legal name:* First Name Last Name Child #1 legal name:* First Name Last Name Child #1 legal name:* First Name Last Name Child #1 legal name:* First Name Last Name Hebrew Name: If known First Name Last Name Hebrew Name: If known First Name Last Name Hebrew Name: If known First Name Last Name Hebrew Name: If known First Name Last Name Child #1 Date of Birth:* 1 - January2 - February3 - March4 - April5 - May6 - June7 - July8 - August9 - September10 - October11 - November12 - December Month12345678910111213141516171819202122232425262728293031 Day20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 Year Child #1 Date of Birth:* 1 - January2 - February3 - March4 - April5 - May6 - June7 - July8 - August9 - September10 - October11 - November12 - December Month12345678910111213141516171819202122232425262728293031 Day20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 Year Child #1 Date of Birth:* 1 - January2 - February3 - March4 - April5 - May6 - June7 - July8 - August9 - September10 - October11 - November12 - December Month12345678910111213141516171819202122232425262728293031 Day20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 Year Child #1 Date of Birth:* 1 - January2 - February3 - March4 - April5 - May6 - June7 - July8 - August9 - September10 - October11 - November12 - December Month12345678910111213141516171819202122232425262728293031 Day20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 Year Please indicate time of birth as:* Before SunsetAfter SunsetUnknown Please indicate time of birth as:* Before SunsetAfter SunsetUnknown Please indicate time of birth as:* Before SunsetAfter SunsetUnknown Please indicate time of birth as:* Before SunsetAfter SunsetUnknown School child #1 is attending in the fall: School child #1 is attending in the fall: School child #1 is attending in the fall: School child #1 is attending in the fall: Grade child #1 is entering in the fall:* Kindergarten1st2nd3rd4th5th6th7th8th Grade child #1 is entering in the fall:* Kindergarten1st2nd3rd4th5th6th7th8th Grade child #1 is entering in the fall:* Kindergarten1st2nd3rd4th5th6th7th8th Grade child #1 is entering in the fall:* Kindergarten1st2nd3rd4th5th6th7th8th Is child #1 adopted?:* YesNo Is child #1 adopted?:* YesNo Is child #1 adopted?:* YesNo Is child #1 adopted?:* YesNo List any medications Child #1 takes:* enter N/A if not applicable List any medications Child #1 takes:* enter N/A if not applicable List any medications Child #1 takes:* enter N/A if not applicable List any medications Child #1 takes:* enter N/A if not applicable List any allergies Child #1 has to food or medications:* enter N/A if not applicable List any allergies Child #1 has to food or medications:* enter N/A if not applicable List any allergies Child #1 has to food or medications:* enter N/A if not applicable List any allergies Child #1 has to food or medications:* enter N/A if not applicable Does child #1 need an epi-pen?:* YesNo Does child #1 need an epi-pen?:* YesNo Does child #1 need an epi-pen?:* YesNo Does child #1 need an epi-pen?:* YesNo Does child #1 have any medical, developmental or behavioral issue that we should know about?:* Option 1Option 2Option 3 Does child #1 have any medical, developmental or behavioral issue that we should know about?:* Option 1Option 2Option 3 Does child #1 have any medical, developmental or behavioral issue that we should know about?:* Option 1Option 2Option 3 Does child #1 have any medical, developmental or behavioral issue that we should know about?:* Option 1Option 2Option 3 Can child #1 read basic Hebrew?:* YesNo Can child #1 read basic Hebrew?:* YesNo Can child #1 read basic Hebrew?:* YesNo Can child #1 read basic Hebrew?:* YesNo Child #2 Child #2 Child #2 Child #2 legal name: First Name Last Name Child #2 legal name: First Name Last Name Child #2 legal name: First Name Last Name Hebrew Name: If known First Name Last Name Hebrew Name: If known First Name Last Name Hebrew Name: If known First Name Last Name Child #2 Date of Birth: 1 - January2 - February3 - March4 - April5 - May6 - June7 - July8 - August9 - September10 - October11 - November12 - December Month12345678910111213141516171819202122232425262728293031 Day20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 Year Child #2 Date of Birth: 1 - January2 - February3 - March4 - April5 - May6 - June7 - July8 - August9 - September10 - October11 - November12 - December Month12345678910111213141516171819202122232425262728293031 Day20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 Year Child #2 Date of Birth: 1 - January2 - February3 - March4 - April5 - May6 - June7 - July8 - August9 - September10 - October11 - November12 - December Month12345678910111213141516171819202122232425262728293031 Day20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 Year Please indicate time of birth as: Before SunsetAfter SunsetUnknown Please indicate time of birth as: Before SunsetAfter SunsetUnknown Please indicate time of birth as: Before SunsetAfter SunsetUnknown School child #2 is attending in the fall:* School child #2 is attending in the fall:* School child #2 is attending in the fall:* Grade child #2 is entering in the fall: Kindergarten1st2nd3rd4th5th6th7th8th Grade child #2 is entering in the fall: Kindergarten1st2nd3rd4th5th6th7th8th Grade child #2 is entering in the fall: Kindergarten1st2nd3rd4th5th6th7th8th Is child #2 adopted?: YesNo Is child #2 adopted?: YesNo Is child #2 adopted?: YesNo List any medications Child #2 takes: enter N/A if not applicable List any medications Child #2 takes: enter N/A if not applicable List any medications Child #2 takes: enter N/A if not applicable List any allergies Child #2 has to food or medications: enter N/A if not applicable List any allergies Child #2 has to food or medications: enter N/A if not applicable List any allergies Child #2 has to food or medications: enter N/A if not applicable Does child #2 need an epi-pen?: YesNo Does child #2 need an epi-pen?: YesNo Does child #2 need an epi-pen? YesNo Does child #2 have any medical, developmental or behavioral issue that we should know about?: Option 1Option 2Option 3 Does child #2 have any medical, developmental or behavioral issue that we should know about?: Option 1Option 2Option 3 Does child #2 have any medical, developmental or behavioral issue that we should know about?: Option 1Option 2Option 3 Can child #2 read basic Hebrew?: YesNo Can child #2 read basic Hebrew?: YesNo Can child #2 read basic Hebrew?: YesNo Child #3 Child #3 Child #3 legal name: First Name Last Name Child #3 legal name: First Name Last Name Hebrew Name: If known First Name Last Name Hebrew Name: If known First Name Last Name Child #3 Date of Birth: 1 - January2 - February3 - March4 - April5 - May6 - June7 - July8 - August9 - September10 - October11 - November12 - December Month12345678910111213141516171819202122232425262728293031 Day20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 Year Child #3 Date of Birth: 1 - January2 - February3 - March4 - April5 - May6 - June7 - July8 - August9 - September10 - October11 - November12 - December Month12345678910111213141516171819202122232425262728293031 Day20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 Year School child #3 is attending in the fall:* School child #3 is attending in the fall:* Grade child #3 is entering in the fall: Kindergarten1st2nd3rd4th5th6th7th8th Grade child #3 is entering in the fall: Kindergarten1st2nd3rd4th5th6th7th8th Is child #3 adopted?: YesNo Is child #3 adopted?: YesNo List any medications Child #3 takes: enter N/A if not applicable List any medications Child #3 takes: enter N/A if not applicable List any allergies Child #3 has to food or medications: enter N/A if not applicable List any allergies Child #3 has to food or medications: enter N/A if not applicable Does child #3 need an epi-pen?: YesNo Does child #3 need an epi-pen?: YesNo Does child #3 have any medical, developmental or behavioral issue that we should know about?: Option 1Option 2Option 3 Does child #3 have any medical, developmental or behavioral issue that we should know about?: Option 1Option 2Option 3 Can child #3 read basic Hebrew?: YesNo Can child #3 read basic Hebrew?: YesNo Child #4 Child #4 legal name: First Name Last Name Hebrew Name: If known First Name Last Name Child #4 Date of Birth: 1 - January2 - February3 - March4 - April5 - May6 - June7 - July8 - August9 - September10 - October11 - November12 - December Month12345678910111213141516171819202122232425262728293031 Day20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 Year Please indicate time of birth as: Before SunsetAfter SunsetUnknown School child #4 is attending in the fall: Grade child #4 is entering in the fall: Kindergarten1st2nd3rd4th5th6th7th8th Is child #4 adopted?: YesNo List any medications Child #4 takes: enter N/A if not applicable List any allergies Child #4 has to food or medications: enter N/A if not applicable Does child #4 need an epi-pen?: YesNo Does child #4 have any medical, developmental or behavioral issue that we should know about?: Option 1Option 2Option 3 Can child #4 read basic Hebrew?: YesNo Pick-up Authorization List name(s) of those, other than parents, who are authorized to pick up your child(ren): Total: $0.00 Payment Methods:* Credit Card Paypal Zelle Credit Card We accept Visa, MasterCard, American Express, Discover Credit Card Number Security Code Name on Card1 - January2 - February3 - March4 - April5 - May6 - June7 - July8 - August9 - September10 - October11 - November12 - December Expiration Month2026202720282029203020312032203320342035 Expiration YearPaypal has been selected. Payment will take place on the next page.ZELLE: 561-303-9805Billing Address Street Address City State / Province Postal / 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 SaharaYemenZambiaZimbabweOther Country ZELLE: 561-303-9805 Medical Emergency I hereby give permission, in the event of an emergency, for the Director, Acting Director, or to whoever's in charge from Chabad Hebrew School to take whatever steps may be necessary for the medical care of my child. I understand that in order for Chabad Hebrew School to assume responsibility for my child, I, or the person(s) whom I have designated to drop off and pick up my child, must sign my child in at the time of arrival and out at the time of departure. I understand that unless there is a need for immediate action, the order of the steps taken will follow, but will not be limited to, the outline below: 1. The parent/guardian will be called. Note: If the parent/guardian is unavailable, the emergency contact person designated by the parent/guardian will be called. 2. If these efforts are unsuccessful the following steps will be taken (order may vary depending on the situation): a. A physician will be called. b. The child will be taken to the nearest emergency room accompanied by a staff member. c. An ambulance will be called to take the child to the nearest emergency room accompanied by a staff member. In the event of an emergency, if I cannot be reached, I give consent for a Chabad staff member to transport my child to the nearest emergency facility, or to have my child transported by ambulance. I give consent to any emergency facility and physician to administer any necessary medical treatment to my child as the situation may warrant it. Emergency Contact Name:* First Name Last Name Emergency Contact Cell Phone*:* If parents cannot be reached and emergency medical advice is needed, permission is given to Chabad Hebrew School staff to phone my child's doctor. In case of a medical emergency requiring immediate emergency care, I authorize the paramedics to take my child to the nearest hospital, if necessary. It is understood that I will hold Chabad of Boca Raton West and Hebrew School harmless for the nature and outcome of any emergency medical treatment. It is also understood that I leave the decision of what constitutes an emergency to the sole direction of the staff. Parent Electronic Signature I have provided information, consent, authorization and agreement where indicated, and the information I provided is accurate. Type first and last name of parent completing this form, to be used as your electronic signature.* * First Name Last Name Please send a confirmation email to: * I would like to receive news and updates by email Submit Should be Empty: This page uses TLS encryption to keep your data secure.
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