Student Information:

Name:                                             Hebrew Name:                                  Birth date: M/D/Y
     Grade entering:

Emergency Contact:                                            Home Phone:                            Work Phone:                      Mobile Phone:
   
Doctor:                                                                                                                                                         Phone Number:
 
Address:                                                                                  City:                                                                   State:        Zip:
   
Allergies or other Medical Condition:

Tuition Information: 

$100 for the first child. ($85 for each additional child.) 

Please pay as much as you can towards the tuition cost. No child will be turned down due to lack of payment.
I will mail in a check made payable to Chabad in the amount of  

As the parent(s) or legal guardian of  I/we authorize any adult acting on behalf of Chabad of Central Oregon to obtain emergency medical care as the situation mandates. I agree that Chabad of Central Oregon, its administration and staff, will not be liable for any injury or health impairment that may occur.