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Child's Info
Child's Name*

First Name Last Name
Hebrew Name If available
Birth Date*

Month Day Year
Grade Entering
School Attending
Previous Jewish Education?
Hebrew reading proficiency
Any special learning, behavioral needs or any family or living issues?
Additional Comments
Parent's Info
Father's Name

First Name Last Name
Hebrew Name If available
Home

Area Code Phone Number
Cell

Area Code Phone Number
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Do you have Whatsapp Messenger Service?
E-mail
Mother's Name

First Name Last Name
Hebrew Name If available
Home

Area Code Phone Number
Cell

Area Code Phone Number
Do you have Whatsapp Messenger Service?
E-mail

Address

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

Are the natural father, mother and maternal grandmother of the child Jewish?*

YesNo
Have there been any conversions or adoptions in the family?*

YesNo
Did someone refer you? How did you find out about our program?
Emergency Information & Terms
In the rare case that there is an emergency and we cannot reach either parent, please let us know who we can contact.
Emergency Contact 1

First Name Last Name
Home

Area Code Phone Number
Cell

Area Code Phone Number
Emergency Contact 2

First Name Last Name
Home

Area Code Phone Number
Cell

Area Code Phone Number
Doctor's Name

First Name Last Name
Doctor's Number

Area Code Phone Number
Allergies or other Medical Condition
What is your preference for reminder messageing?
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Agreement
As parent(s) or legal guardian of the above child, I/we authorize any adult acting on behalf of Ckids Hebrew School/Chabad of Rancho Mirage to hospitalize or secure treatment for my child. This includes all medical transportation, medical and surgical treatment, X-ray, laboratory, anesthesia, and other medical and/or hospital procedures which may be performed or prescribed by the attending physician and/or paramedics for my child and waive my right to informed consent of treatment. I further agree to pay all charges for that care and/or treatment. This waiver applies only in the event that neither parent/guardian can be reached in the case of an emergency.

I allow my child to be photographed and for the photos to be used in print, video and digital media.

I hereby give permission for my child to attend all field trips and outings sponsored by CKids Hebrew School.
Agreement*

I have read the terms and conditions as laid out above and accept.
Amount to Charge

$50 down payment. Upon acceptance you will receive a contract. See Dates & Rates for total tuition fees.
Registration - $50
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Educate Your Child... Educate a Generation

Child's Info

Parent's Info

Emergency Information & Terms

Agreement

Amount to Charge