Student Application Form

Last Name: __________________________ Child’s First Name: ___________________

Date of Birth: ________________________ Hebrew Name: _______________________

Address: ________________________________________________________________________________________________________________________________________________

Home Telephone: _______________________________

Is there any special information we should know about your child? If yes, please elaborate. You may use another paper if necessary. ______________________________________________________________

Has your child attended Hebrew School programs before? ___ If yes, which one? ______________________________________________________________

Current School and Grade:

______________________________________________________________

What is your child’s Hebrew reading background? ( please check one)

__ none yet

__ familiar with Hebrew Alphabet

__ fluent in Hebrew Alphabet

__ reads Hebrew

Parent information:

Father’s Information:

Child’s Father’s Name: ____________________________

Father’s Occupation: _______________________

Company Name: __________________________

Company Address: ________________________

Company Phone: __________________________

Cell Phone: ______________________________

E-mail Address: ______________________________________________________________________

Mother’s Information:

Mother’s Name: ___________________________

Mother’s Occupation: _______________________

 Company Name: ___________________________

Company Address: __________________________

Company Phone: __________________________

Cell Phone: _________________________________

Have there been any conversions in the family? ___ If yes, please elaborate:________________________

Was the child born to a Jewish mother? Yes ___ No ___ (Jewish Law mandates that we ask this question)

Are you a member of a Synagogue? Yes ___ No ___

Which one? _______________________________

Names and ages of other siblings:

_________________________________________________________

Health Information:

Pediatrician’s Name: __________________________

Phone Number: ____________________________

Address: ________________________________________________________________________

Insurance provider and number: __________________________________________________________________

Allergies or Medical Conditions: _________________________________________________________

In case of emergency, please contact: (other than parent)

1. __________________________________

Address: ________________________________________

Relationship to child: ___________________________ Phone:________________________________

2. __________________________________

Address: ________________________________________

Relationship to child: ___________________________ Phone:________________________________

Permission to Receive Emergency Care

I hereby grant permission to Beekman Hebrew School to take whatever steps

are necessary to obtain emergency medical care if warranted. These steps may include but are not limited to the following:

1. Attempt to contact parent.

2. Attempt to contact child’s physician.

3. Attempt to contact emergency contact person.

If we cannot contact the above, we will do all or any of the following:

1. Call another physician.

2. Call an ambulance.

3. Have the child taken to the nearest emergency room at a hospital by a staff member.

Any expenses incurred under the circumstances will be borne by the child’s family.

 I hereby allow Beekman Hebrew to take my child off school grounds for all trips, outings, and walks.

Parent’s signature: ________________________________ Date:________________________

Thank  you for choosing Beekman Hebrew! Please complete the registration information and mail those forms, together with $175 registration fee (towards tuition) to:

Chabad at Beekman-Sutton

308 East 51^st Street #1

New York, N.Y. 10022