ENROLMENT CHILD 1 INFORMATION Surname First Name Hebrew name (if known) Date of Birth (dd/mm/yyyy) Gender Male Female Grade (2019) School MEDICAL INFORMATION Any medical conditions Drug/Food allergies Is tetanus booster up to date Is an EPIPEN Required No YES - EPIPEN CHILD 2 INFORMATION First Name Hebrew name (if known) Date of Birth (dd/mm/yyyy) Gender Male Female Grade (2019) School MEDICAL INFORMATION Any medical conditions Drug/Food allergies Is tetanus booster up to date Is an EPIPEN required No YES - EPIPEN MOTHERS INFORMATION Surname First Name Email Home Phone Mobile FATHERS INFORMATION Surname First Name Email Home Phone Mobile CHILDS PRIMARY ADDRESS Street Number and Name Postcode Marital Status Is the natural mother of the child Jewish Yes No Are there any conversions in the family Yes No If yes, please give further details including place of conversion Shul affiliation if any EMERGENCY INFORMATION Full Name Relationship to child Phone Mobile Local GP Name Local GP Phone AUTHORISATION FOR PICK UP (IF NOT PARENTS) Full Name of Authorised Person to pick up 1 Phone number of Authorised Person 1 Relation to Child Full Name of Authorised Person to pick up 2 Phone number of Authorised Person 2 Relation to Child OPTIONAL Special remarks Please put my child in the same class as How did you hear about us Attended past day camps Please Choose Friends Advertising Internet search Other - Please specify below Other DECLARATION OF PARENT / GUARDIAN I hereby authorise Chabad on Carlisle-Jewish Russian Centre leaders and staff to obtain any medical care necessary for my child. I understand that in the case of emergency of any significant illness or injury, attempt will be made to contact myself when practical. I agree to pay for any cost that may occur as a result of the injury/illness. I acknowledge my child may be participate in activities within and outside the Chabad grounds. I authorise my child to participate in these activities. I hereby authorise Chabad on Carlisle-Jewish Russian Centre to photograph my child and to use the photographs at their discretion. I agree to the above declaration. Full Name Date Fees $180 per term per child Please note that no child will be turned away due to lack of funds. Please contact the office at 9527 6341 to discuss any financial considerations. Enrolment fee Secure online payment CREDIT CARD Card Type Visa Master Card Name on card Card number Exp Amount Direct Debit Details I authorise Chabad on Carlisle - Jewish Russian Centre to debit the above credit card at the start of each school term ($180 per child). This page uses 128 bit SSL encryption to keep your data secure.
