Registration Form

COMMUNITY HEBREW ACADEMIC INSTITUTE
Temple Emmanuel, 120 Chestnut Street
Wakefield, Massachusetts 01880

Name of student ___________________________________________________

Date of birth ___________________________________________________

Grade in public school ___________________________________________________

Name of public school ___________________________________________________

Hebrew name ___________________________________________________

Hebrew grade entering ___________________________________________________

Do you have a Prayer Book? Yes____ No ____ Each family is required to have one Prayer Book at home

Special needs/learning difficulties:

Father’s name ___________________________________________________

Mother’s name ___________________________________________________

Address ___________________________________________________

Home telephone # ___________________________________________________

Emergency Telephone # ___________________________________________________

Temple affiliation ___________________________________________________

Names of other children in car pool ____________________________________________________

Names of drivers of car pool _________________________________________________________

Cell phone # ________________________ E-mail address ______________________

For Pre-Hebrew School, child should be in the first grade of public school. For Hebrew School, child should be in the third grade of public school.

To assist in the defraying of cost and to meet needs of certain holidays, the Chai Board ask for your assistance. Please indicate below where you are willing to help.

Bottle Drive (indicate month)	__________
Shabbat hostess assistance	__________
Kiddush Assistance	__________

Chanukah breakfast	_______________
Tu B’shvat Seder	_______________
Passover Model Seder	_______________

Food Allergies/other: ____________________________________

In the case of a medical emergency, I give the CHAI School of Temple Emmanuel, 120 Chestnut St.,

Wakefield, MA, permission to have my child, __________________________, transported to the nearest medical facility for emergency medical treatment.

Signature of parent/guardian _________________________________

Name of physician: _________________________________

Physician address & phone number: ___________________________________________________

(_____)_________________

Name of insurance provider: ___________________________________

Policy number: ______________________

Name of policy holder: __________________________________