New Student Registration

Student Information:
Full Name*
First Name Last Name
Hebrew Name: *
Gender: *
Grade entering in September:*
Birth Date*

Month Day Year
Time of Day:*
Hour Minutes
School Currently Attending:*
Family Information:
All family information is the same as the first child.

Address*

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Home Phone Number: *

Area Code Phone Number
Father's Name:*
Hebrew Name:*
Work Phone Number:

Area Code Phone Number
Cell Phone Number:

Area Code Phone Number
Mother's Name: *
Hebrew Name:*
Work Phone Number:*

Area Code Phone Number
Cell Phone Number:*

Area Code Phone Number
Mother's E-mail:*
Father's E-mail:*
Which email would you like used for updates and newsletters?*

Mother'sFather'sBoth
Marital Status:*

MarriedSingleDivorced
Religous and Educational:
Previous Jewish Education:*
Does your child read basic Hebrew?*

NoneSomewhatWell
Does your child have any learning difficulties with General Studies?*

YesNo
If yes, please describe:
Is the natural mother of the child Jewish?*

YesNo
Is the natural father of the child Jewish?*

YesNo
Are there any conversions and/or adoptions in the family?*

YesNo
Medical Information:
Is there any special medical or other information that we should be aware of?*

YesNo
If yes, please describe:
Does your child have any allergies?*

YesNo
Is your child currently taking any medication?*

YesNo
Family Physician:*
Physician's Phone Number:*

Area Code Phone Number
Emergency Contact #1:*
Relation: *
Phone Number:*

Area Code Phone Number
Emergency Contact #2:*
Relation: *
Phone Number:*

Area Code Phone Number
Medical Release:*

I hereby give consent to the administration of the CHAI Family Academy to take whatever medical measures they deem necessary, at my expense, for my child in the event of a medical emergency.
Permission Slips:*

I grant permission for my child to be photographed in individual or group pictures which may be used by CHAI Family Academy for P.R.
How did you hear about CHAI Family Academy?
Registration*

I would like to register my child for the 2023/2024 session $800
Please accept my payment of:*

$
Total

$0.00

Payment

Credit Card

We accept Visa, MasterCard, American Express, Discover
Credit Card Number	Security Code
Name on Card
Expiration Month	Expiration Year

Billing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Should be Empty:

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