Super Jew Registration

Family Name

Home Number

Area Code Phone Number

Home Address

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

Mother's Name

First Name Last Name

Mother's Hebrew Name

Mother's Number

Area Code Phone Number

Mother's Email

Father's Name

First Name Last Name

Father's Hebrew Name

Father's Number

Area Code Phone Number

Father's Email

Child #1

Child's Name

Child's Hebrew Name

Child's Age

Date of Birth

Month Day Year

Child #2

Child's Name

Child's Hebrew Name

Child's Age

Date of Birth

Month Day Year

Child #3

Child's Name

Child's Hebrew Name

Child's Age

Date of Birth

Month Day Year

Comments

Is the biological mother of the child Jewish?

YesNo

Is the mother's mother Jewish?

YesNo

Is the biological father of the child Jewish?

YesNo

Is the father’s mother Jewish?

YesNo

Have there been any conversions or adoptions in the family history?

YesNo

If yes please include all backup information & documentation.

Please note all conversions must be made through a registered Beth Din that is certified by the Israel Rabbinate.

Emergency Contact

First Name Last Name

Emergency Contact Number

Area Code Phone Number

Relationship to Child

Persons authorized to pick up my child

Special instructions (allergies, psychological or medical conditions, medications currently being taken, dietary requirements etc...)

Physician’s name

Physician’s number

Area Code Phone Number

Physician’s address

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

Insurance company covering the child

Policy number

Expiration date

I hereby give permission, in the event of an emergency, for the Director, the Acting Director, or the Teacher at Chabad of Montville to take whatever steps maybe necessary for the medical care of my child(ren),

Child(ren)

I understand that unless there is a need for immediate action, the order of the steps taken will follow, but will not be limited to, the outline below:

1. The parent/Guardian will be called.

Note: If the parent/guardian is unavailable, the emergency contact person designated by the parent/guardian will be called.

2. Child's physician will be called.

3. If these efforts are unsuccessful the following steps will be taken (order may vary depending

on the situation):

a. Another physician will be called.

b. The child will be taken to the nearest emergency room accompanied by a staff member.

c. An ambulance will be called to take the child to the nearest emergency room accompanied by a staff member.

In the event of an emergency, if I cannot be reached, I give consent for a Chabad staff member to transport my child to the nearest emergency facility, or to have my child transported by ambulance.

I give consent to any emergency facility and physician to administer any necessary medical treatment to my child as the situation may warrant it.

Parent initial

Parent name

Date

Choose to register for:
1) Individual classes (as many as you like) for $15/class
2) Entire Session - $80/session

Make your selection:

May 21 - $15

Total

$0.00

Payment

Credit Card Check

Postal / Zip Code

Country

CC Security code

I would like to receive news and updates by email

Family Information

Student Information

General Information

Medical Information

Schedule

Holiday Session

Mitzvah Mensch Session

Bonus Torah Class