Ohav Sholom's After School Hebrew School

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Child's information

* Child's first name

* Last name

* Hebrew name

Street address

Street address line 2

City

Zip code

Home phone

Cell phone number

* Child's birthday

Public School Grade as of 9/22

Name of school

Gan - KAlef -1Bet -2Gimmel - 3Dalet - 4Hay - 5Vav - 6Zayin - 7

Parent information

Mother's first name

Mother's phone number

Mother's email address

Please choose one:

Born JewishConverted

Father's first name

Father's phone number

Father's email address

Please choose one:

Born JewishConverted

Are there any special learning needs the school should be aware of?

Are there any medical or personal needs the school should be aware of?

Physician's name

Physician's phone number

Emergency information:

Emergency contact #1: Name

Phone number

Relationship

Emergency contact #2: Name

Phone number

Relationship

* In the event of a medical emergency, if I cannot be reached or my emergency contact listed above cannot be reached, Congregation Ohav Sholom has my permission to obtain Medical Treatment for my child by a physician the synagogue has on call. *

I allow Ohav Sholom to use my child(ren)'s photos on social media and/or other promotional materials.

(Inital to allow consent)

Additional Info/Requests/Questions

Tue, March 28 2023 6 Nisan 5783