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Address

Phone Number

Area Code Phone Number
E-mail
Mother's Name or Guardian

First Name Last Name
Hebrew Name
Work

Area Code Phone Number
Cell

Area Code Phone Number
E-mail
Father's Name or Guardian

First Name Last Name
Hebrew Name
Work

Area Code Phone Number
Cell

Area Code Phone Number
E-mail
Name/s of Siblings
Schools Siblings attend
Siblings' DOB
Was the child born Jewish?

YesNo
Were there any conversions or adoptions in the family?

YesNo
If yes, who was the Rabbi?
Additional Comments
Emergency File
Doctor's Name
Allergies
Medical Conditions
Emergency Contact 1

First Name Last Name
Phone

Area Code Phone Number
Relationship
Emergency Contact 2

First Name Last Name
Phone

Area Code Phone Number
Relationship
PERMISSION FOR EMERGENCY MEDICAL TREATMENT:

As the parent(s) or legal guardian, I/we authorize any adult acting on behalf of Chabad of the Beaches to hospitalize or secure treatment for my child. I further agree to pay all charges for that care and/or treatment. It is understood that if time and circumstances reasonably permit, Chabad of the Beaches personnel will try, but are not required, to communicate with me prior to such treatment. I hereby give permission for my child to attend all field trips and outings sponsored by Chabad of the Beaches.
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