Chai Daycare Register Form - Chabad Jewish Center of Prospect Heights

Registration 2018-2019
1. Child's Information
Child*
First NameHebrew NameLast Name
Birth Date*
MonthDayYear
Age in September*
Gender*

Child's Address*

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Home Phone Number*
Area CodePhone Number
Does your child have any previous childcare experience? If yes, de we have permission to contact them?
Childcare Phone Number
Area CodePhone Number
Are there any physical disabilities or medical conditions that require accommodations or services? Please explain.
Does your child have any allergies?
Is there special food or eating instructions?
Is there any specific napping or sleeping instructions?
Does your child have any bowel or bladder irregularities?
What language is spoken at home?
Is there any additional information, such as child's communication, comfort, or family circumstances that you feel we should know about?
2. Parent/Guardian Information
Parent/Guardian 1*
First NameHebrew NameLast Name
Jewish*
YesNo

Address*

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Work Phone*
Area CodePhone Number
Cell Phone*
Area CodePhone Number
E-mail*Primary email
Parent/Guardian 2*
First NameHebrew NameLast Name
Jewish*
YesNo

Address*

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Work Phone*
Area CodePhone Number
Cell Phone*
Area CodePhone Number
E-mail*Primary E-mail
How did you hear about Chai Daycare?
3. What hours are you interested in?
A. 8:00 AM-1:00 PM
B. 8:00 AM-3:00 PM
C. 8:00 AM-4:00 PM
D. 8:00 AM-6:00 PM
Are you interested in any specific days of the week, or are you flexible? Please specify.*
We cannot guarantee your preferred dates. Remember, we can best provide for those who are flexible.
When would you like your child to begin?*
MonthDayYear
What ending date would you like?*
* Please note that if there will be a fee if there will be any changes made to the schedule above.
An additional $75 will be charged to anyone who changes their child's schedule before the first week of school. A $150 fee will be charged after the first week of school.
Changes will be made upon the school's discretion.
4. Pick Up
Person's authorized to pick up child
5. Family Information
Sibling(s); Please indicate ages and if they live with your child.
Please list any other person(s) living with your child and their relationship to the child.
Are you affiliated with any synagogue or religious organization?
If yes please specify
6. Emergency Contact Information
Please indicate telephone numbers where you and another authorized person can be contacted in case of emergency.
Parent's Name*
Phone Number
Parent's Name*
Phone Number
Additional Authorized Person*
First NameLast Name
Relationship to child*
Phone Number*
Area CodePhone Number
Address
7. Child's Health Care Information
Child's Name
First NameLast Name
Child's Pediatrician
First NameLast Name
Pediatrician's Phone Number
Area CodePhone Number
Pediatrician's Address
7. Emergency Care
In case of an emergency, I authorize the staff to provide any First Aid care deemed necessary for my child.
In case of an emergency in which I cannot be reached, the pediatrician listed above and the local hospital are hereby authorized to provide any emergency care deemed necessary for my child.
In case of emergency, I hereby authorize the transfer of my child's records to the local hospital.
I hereby agree to the above and give my permission to care for my child in case of emergency, including medical care or first aid; transfer of care to my child's pediatrician or local hospital and health records transfer.
Signature
Today's Date
MonthDayYear
8. Permission for Trips
I give permission to my son/daughter to participate in supervised curricular and extracurricular activities that may include leaving the daycare building.
Signature
Parent/Guardian
Today's Date
MonthDayYear
9. Permission for Pictures
Agreement
I give Chai Daycare permission for pictures and videos to be taken of my child and used as seen fit.
Agreement
I choose not to have any pictures or videos published of my child.
Signature
Parent/Guardian
Today's Date
MonthDayYear
I will not hire any staff member as a personal babysitter or in any other capacity.
Signature
Parent/Guardian
Today's Date
MonthDayYear
I have reviewed the guidelines and I hereby register my child 2018– 2019 school year.
Signature
Today's Date
MonthDayYear
10. Payment Information
A $206 non-refundable registration fee applies as part of this registration.
Non-refundable registration fee*(Plus 3% CC Processing fee)
$206

Payment*

Credit Card

Credit Card Type
Credit Card Number	Security Code
Name on Card
Expiration Month	Expiration Year

General comments
Chai Day Care Office:
569 Vanderbilt Ave. Brooklyn, NY 11238
Please make checks payable to Chai.
Should be Empty:

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1. Child's Information

2. Parent/Guardian Information

3. What hours are you interested in?

4. Pick Up

5. Family Information

6. Emergency Contact Information

7. Child's Health Care Information

7. Emergency Care

8. Permission for Trips

9. Permission for Pictures

10. Payment Information