Student Registration Form

Please ensure your family account is paid in full prior to enrolling in our school. All personal information will be kept strictly confidential.
Child's Name
First Name Last Name Hebrew Name Date of Birth Secular School Any Food Allergies
Provide any learning, behavioral, speech or fine motor concerns of which you believe we should be aware, in addition to any special services your child receives at school (Please specify child if listing more than one):
Please list any medical conditions of which we should be aware (please specify child if listing more than one):
Parent/Guardian Name(s):
First Name Last Name Hebrew Name Phone Number Email Address
Child's Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Parent's Address (if different than child's)
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Emergency Contacts (if parent/guardians are unvailable)
Name Relationship Cell Phone Home Phone
Emergency Care Permission Although the recommendation of the parent will be respected as much as possible, I understand that in the final disposition of an emergency case, the judgment of the adults on site will prevail. I hereby give permission to JCNWJ Personnel to seek emergency medical treatment from the physician of their choice for my child.

First Name	Last Name	Hebrew Name	Date of Birth	Secular School	Any Food Allergies

First Name	Last Name	Hebrew Name	Phone Number	Email Address

Name	Relationship	Cell Phone	Home Phone

Please ensure your family account is paid in full prior to enrolling in our school. All personal information will be kept strictly confidential.