Chabad of Dumbo Application Form - Chabad of Dumbo
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Child Information
       
Last Name
First Name
  Hebrew Name
Gender
DOB
  Home Phone
Address
City, State, Zip
 
       
Sibling 1Name
Age
  School Attending
Sibling 2 Name
Age
  School Attending

Parent Information
Mother
       
Mother's Name Hebrew Name
  Occupation
Firm Name
Firm Address
  Firm Phone
Cell
Email Address   Country of Origin
Father
       
Father's Name Hebrew Name
  Occupation
Firm Name
Firm Address
  Firm Phone
Cell
Email Address   Country of Origin

General Family Information
 
Is your family affiliated with a congregation?
If yes, which one?
Does the child live with both natural parents?
Is the child's natural mother Jewish?
Are there any adoptions in your family?
Are there any Conversions in your family?
You may arrange to discuss these issues with our Rabbi

Emergency Contact
       
Name
Phone
  Relation to child
Name
Phone
  Relation to child
Pediatritian
Phone
  Address

General Child Information
 
Allergies
For snack my child likes to eat
For lunch my child likes to eat
My child loves to
When child is upset, what calms him/her down?
Language(s) spoken at home
Language(s) spoken by child
How does your child respond to new situations?
Any other information you would like us to know about your child:
     
Please select desired program   Preschool Length of Day
2's Class | 5 Days - Mon-Fri   Full Day  9:00am - 2:30pm
2's Class | 3 Days - Mon/Wed/Fri   Half Day  9:00am - 12:30pm
3's Class | 5 Days - Mon-Fri    Extended Care until 4:00pm 
   
How did you hear about our Preschool?
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