Child's Name
First Name
Last Name
Chadash Community Hebrew Academy
Registration/ Emergency Form 2022-2023/5782-5783
Child's Information
Child's Name
First Name
Last Name
Child's Nickname or Preferred Name
Child's Preferred Pronouns
Child's Primary Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Birth Date
-
Month
-
Day
Year
Date
Grade Entering in the Fall
School Attending
Hebrew Name
Congregational Affiliation
Temple Israel
Shaaray Torah Synagogue
Parent 1 Information
Parent 1's Name
First Name
Last Name
Address (if different than above)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Cell Phone
Please enter a valid phone number.
Home Phone
Please enter a valid phone number.
Email Address
example@example.com
Parent 2 Information
Parent 2's Name
First Name
Last Name
Address (if different than above)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Cell Phone
Please enter a valid phone number.
Home Phone (if different than above)
Please enter a valid phone number.
Email Address
example@example.com
Emergency Contacts (please list 3)
Emergency Contact 1 Name
Relationship to Child
Phone
Please enter a valid phone number.
Emergency Contact 2 Name
Relationship to Child
Phone
Please enter a valid phone number.
Emergency Contact 3 Name
Relationship to Child
Phone
Please enter a valid phone number.
Learning Needs
Does your child have an IEP or a 504 plan in place in their school?
YES
NO
Please describe any learning challenges your child may have:
Emergency Information
Medical Alerts (allergies, etc.):
Medicines:
Physician Name:
Physician Office Phone:
Please enter a valid phone number.
Dentist Name:
Dentist Office Phone:
Please enter a valid phone number.
Insurance Company:
Policy#
Group#
Treatment Consent: In the event that reasonable attempts to contact the parent(s)/guardian(s) at the above mentioned telephone numbers have been unsuccessful, I/we hereby give my/our consent for any treatment deemed necessary by the above physician ordentist. I give permission to Chadash and its employees, in an emergency, to obtain services for my child named above from the facility listed below or the nearest medical facility available.
Preferred facility
Additional Information
Please list any special skills, talents or hobbies you may be able to share with your child’s class or the Chadash community:
Additional comments or information you would like us to know about your child:
Photo and Video Release: I understand that the events in which my child is participating may be photographed or video recorded by either amateur or professional photographers. The photographs taken may be used in print or electronic form on the internet forpurposes of reporting on the event, promoting future events or for such other use as Chadash may determine. I have no objection to these pictures being used at any time for promotional use by Chadash.
YES
NO
Field Trip Permission Slip: I give my son/daughter permission to attend Chadash field trips during the school year 2022-2023. I will assume responsibility for my child’s actions and will not hold Chadash, Temple Israel, or Shaaray Torah liable for loss of personal items or accidents that may occur during any of these events. I will allow my son/daughter to be treated by proper medical personnel should the need arise – at the discretion of the Chadash staff.
YES
NO
Parent Signature
Signature
Clear
Submit
Should be Empty: