Register Online - Chabad of the Beaches

Address

Phone Number
Area CodePhone Number
E-mail
Mother's Nameor Guardian
First NameLast Name
Hebrew Name
Work
Area CodePhone Number
Cell
Area CodePhone Number
E-mail
Father's Nameor Guardian
First NameLast Name
Hebrew Name
Work
Area CodePhone Number
Cell
Area CodePhone 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 NameLast Name
Phone
Area CodePhone Number
Relationship
Emergency Contact 2
First NameLast Name
Phone
Area CodePhone 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.
Signature
Payment Info
Payment Schedule
Total to be charged today
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