Submitting this form is just one part of the registration process. Other prerequisites for registration are: • Signing of the state mandated Distracted Adult Flier and Influenza Information Sheet - available by request as a PDF • Submitting both your chid's health and immunization form • Submitting the $350 registration fee Parent Email* Full Name of Parent Completing the form* First Name Last Name Family Name* Today's Date* 1 - January2 - February3 - March4 - April5 - May6 - June7 - July8 - August9 - September10 - October11 - November12 - December Month12345678910111213141516171819202122232425262728293031 Day202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 Year How many students sre you registering? 1 Student2 Students3 Students4 Students5 Students6 Students General Student Information Child#1 Full Name First Name Last Name Hebrew Name First Name Last Name Birth Date 1 - January2 - February3 - March4 - April5 - May6 - June7 - July8 - August9 - September10 - October11 - November12 - December Month12345678910111213141516171819202122232425262728293031 Day202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 Year Hebrew Birth Date Child's Gender BoyGirl Child's Preferred Name Grade Entering Toddler3/4 Y.OKindergarten1st2nd3rd4th5th6th7th8th Child Lives With: Both ParentsFatherMother Please list all of your child’s allergies or dietary restrictions (Write "None" if there are none): Does your child take any medication on a regular basis? If yes, give name and purpose of medication(s). Will your child be taking the medication during school time? YesNo During the past 12 months, has your child seen a professional to address mental/emotional health concerns? YesNo Describe any personal situations that may affect student’s ability to attend school on a regular basis: 2.General Student Infomation Child #2 Full Name First Name Last Name Hebrew Name First Name Last Name Birth Date 1 - January2 - February3 - March4 - April5 - May6 - June7 - July8 - August9 - September10 - October11 - November12 - December Month12345678910111213141516171819202122232425262728293031 Day202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 Year Hebrew Birth Date Child's Gender BoyGirl Child's Preferred Name Grade Entering Toddler3/4 Y.O.Kindergarten1st2nd3rd4th5th6th7th8th Child Lives With* Both ParentsMotherFather Please list all of your child’s allergies or dietary restrictions (Write "None" if there are none): Does your child take any medication on a regular basis? If yes, give name and purpose of medication(s). Will your child be taking the medication during school time? YesNo During the past 12 months, has your child seen a professional to address mental/emotional health concerns? YesNo Describe any personal situations that may affect student’s ability to attend school on a regular basis: 3.General Student Information Child#3 Full Name First Name Last Name Hebrew Name First Name Last Name Birth Date 1 - January2 - February3 - March4 - April5 - May6 - June7 - July8 - August9 - September10 - October11 - November12 - December Month12345678910111213141516171819202122232425262728293031 Day202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 Year Hebrew Birth date Child's Gender BoyGirl Child's Preferred Name Grade Entering Toddler3/4 Y.O.Kindergarten1st2nd3rd4th5th6th7th8th Child Lives With Both ParentsMotherFather Please list all of your child’s allergies or dietary restrictions (Write "None" if there are none): Does your child take any medication on a regular basis? If yes, give name and purpose of medication(s). Will your child be taking the medication during school time? YesNo During the past 12 months, has your child seen a professional to address mental/emotional health concerns? YesNo Describe any personal situations that may affect student’s ability to attend school on a regular basis: 4.General Student Information Child#4 Full Name First Name Last Name Hebrew Name First Name Last Name Birth Date 1 - January2 - February3 - March4 - April5 - May6 - June7 - July8 - August9 - September10 - October11 - November12 - December Month12345678910111213141516171819202122232425262728293031 Day202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 Year Hebrew Birth Date Child's Gender BoyGirl Child's Preferred Name Grade Entering Toddler3/4 Y.O.Kindergarten1st2nd3rd4th5th6th7th8th Child lives with Both ParentsMotherFather Please list all of your child’s allergies or dietary restrictions (Write "None" if there are none): Does your child take any medication on a regular basis? If yes, give name and purpose of medication(s). Will your child be taking the medication during school time? YesNo During the past 12 months, has your child seen a professional to address mental/emotional health concerns? YesNo Describe any personal situations that may affect student’s ability to attend school on a regular basis: 5.General Student Information Child #5 Full Name First Name Last Name Hebrew Name First Name Last Name Birth Date 1 - January2 - February3 - March4 - April5 - May6 - June7 - July8 - August9 - September10 - October11 - November12 - December Month12345678910111213141516171819202122232425262728293031 Day202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 Year Hebrew Birth Date Child's Gender BoyGirl Child's Preferred Name Grade Entering Toddler3/4 Y.O.Kindergarten1st2nd3rd4th5th6th7th8th Child Lives With: Both parentsMotherFather Please list all of your child’s allergies or dietary restrictions (Write "None" if there are none): Does your child take any medication on a regular basis? If yes, give name and purpose of medication(s). Will your child be taking the medication during school time? YesNo During the past 12 months, has your child seen a professional to address mental/emotional health concerns? YesNo Describe any personal situations that may affect student’s ability to attend school on a regular basis: 6.General Student Information Child #6 Full Name First Name Last Name Hebrew Name First Name Last Name Birth Date 1 - January2 - February3 - March4 - April5 - May6 - June7 - July8 - August9 - September10 - October11 - November12 - December Month12345678910111213141516171819202122232425262728293031 Day202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 Year Hebrew Birth Date Child's Gender BoyGirl Child's Preferred Name Grade Entering Toddler3/4 Y.O.Kindergarten1st2nd3rd4th5th6th7th8th Child Lives With* Both ParentsMotherFather Please list all of your child’s allergies or dietary restrictions (Write "None" if there are none): Does your child take any medication on a regular basis? If yes, give name and purpose of medication(s). Will your child be taking the medication during school time? YesNo During the past 12 months, has your child seen a professional to address mental/emotional health concerns? YesNo Describe any personal situations that may affect student’s ability to attend school on a regular basis: Family Information Father/Guardian Full Name First Name Last Name Father/Guardian Phone Number Father/Guardian E-mail Father/Guardian Occupation Father/Guardian Work place Phone Number Mother/Guardian Full Name First Name Last Name Mother/Guardian Phone Number Mother/Guardian E-mail Mother/Guardioan Occupation Mother/Guardian Work Place Phone# Is the natural mother of the students Jewish? YesNo Have there been any conversions or adoptions in the family? NoYes Explain Primary parent for all school communications: Father/GuardianMother/Guardian Mailing Address Street Address Street Address Line 2 City State / Province Postal / Zip CodePlease SelectUnited StatesAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanThe BahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChilePeople's Republic of ChinaRepublic of ChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCook IslandsCosta RicaCote d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonThe GambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern MarianaNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint BarthelemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSomalilandSouth AfricaSouth OssetiaSpainSri LankaSudanSurinameSvalbardSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTristan da CunhaTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamBritish Virgin IslandsUS Virgin IslandsWallis and FutunaWestern SaharaYemenZambiaZimbabweOther Country Home Address: (if same as mailing address write “same”) Street Address Street Address Line 2 City State / Province Postal / Zip CodePlease SelectUnited StatesAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanThe BahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChilePeople's Republic of ChinaRepublic of ChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCook IslandsCosta RicaCote d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonThe GambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern MarianaNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint BarthelemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSomalilandSouth AfricaSouth OssetiaSpainSri LankaSudanSurinameSvalbardSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTristan da CunhaTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamBritish Virgin IslandsUS Virgin IslandsWallis and FutunaWestern SaharaYemenZambiaZimbabweOther Country Emergency Contact #1 Relationship to the Child: Emergency Contact #2 Name: Emergency Contact #2 Cell Phone Number: I understand that the following authorized persons are allowed to pick up my child and be contacted as emergency contacts : (other than parent/guardian). Important: Child will be released only to the parent or legal guardian, and persons listed below. The following people will also be contacted and are authorized to remove your child from the facility in case of illness, accident or emergency, if for some reason the parent or legal guardian cannot be reached. Please introduce us to the persons authorized to pick up your child. For the safety of your child, please notify teachers (orally or preferred in writing or text) of who will be picking up your child. We reserve the right to request a photo ID from someone listed below, whom we have not previously met.* Yes My name below attests that I allow the Lamplighters Hebrew Academy to release my child to the above mentioned individuals. CLICK HERE IF YOU WOULD LIKE TO APPLY FOR TUITION ASSISTANCE Medical Information Family Physician: Family Physician Phone Number: Medical Insurance Company: Policy Number: Family Dentist: Family Dentist Phone Number: I understand that I need to submit health forms and immunization records for each child prior to/or on the first day of school. Yes Is your child/ren up to date on his/her/their immunizations YesNo Waiver Release of Liability: I hereby voluntarily release from liability and waive any and all claims or causes of action for personal injury or death occurring to the student or others, or property damage arising from or relating to participation in the above activities, and whether arising from the negligence of Lamplighters Hebrew Academy or otherwise, against Lamplighters Hebrew Academy or any of its officers, agents, directors, teachers, or employees. I hereby release Lamplighters Hebrew Academy from liability for myself and my heirs, executors, administrators and assigns, and I shall indemnify and hold harmless Lamplighters Hebrew Academy from any and all such claims or causes of action, including attorney’s fees or damage to personal property. My signature on this form shall constitute an informed and knowing consent and waiver as required by law. I hereby acknowledge that I understand the effect of releasing Lamplighters Hebrew Academy of all such liability, including that caused by negligence.In case of an emergency, I give permission for my child to receive medical treatment. I, the undersigned parent or guardian do hereby consent to any x-ray examination, anesthetic, medical or surgical diagnosis, or treatment and hospital service that may be rendered to said minor under the general or special treatment, and, hospital service that may be rendered to said minor under the general or special instructions, of our physician or other physician called in any emergency by the Lamplighters Principal, the Rabbi, or responsible adult, in the event I/we cannot be reached, whether such diagnosis or treatment is rendered at the office of said physician or at a licensed hospital. It is understood that conscientious effort will be made to notify me or my spouse before such action is taken, but if this is not possible, the expense of this service will be accepted by me/us. It is understood that this consent is given in advance of any specific diagnosis or treatment being required. This consent shall remain effective until revoked. (By entering your name in the box below, you are effectively providing your signature, indicating that all the information on this form is true and accurate, to the best of your knowledge.) I give permission for my child/ren to be photographed and their photos to be placed in our advertisements, brochures, and websites. This includes but is not limited to: chabadofcharlottecounty.com and other social media platforms. Name of Parent/Guardian: (By entering your name in the box below, you are effectively providing your signature, indicating that all the information on this form is true and accurate, to the best of your knowledge, and that you agree to the terms and conditions stated above unless otherwise noted.) Yearly Field Trip Permission Form: List all Children's Names: has/have permission to participate in field trips sponsored by Lamplighters Hebrew Academy. Transportation on field trips may be by school bus, parent drivers, or walking to nearby locations. YesNo Release of Liability: I hereby voluntarily release from liability and waive any and all claims or causes of action for personal injury or death occurring to the student or others, or property damage arising from or relating to participation in the above activities, and whether arising from the negligence of Lamplighters Hebrew Academy or otherwise, against Lamplighters Hebrew Academy or any of its officers, agents, directors, teachers, or employees. I hereby release Lamplighters Hebrew Academy from liability for myself and my heirs, executors, administrators and assigns, and I shall indemnify and hold harmless Lamplighters Hebrew Academy from any and all such claims or causes of action, including attorney’s fees or damage to personal property. My signature on this form shall constitute an informed and knowing consent and waiver as required by law. I hereby acknowledge that I understand the effect of releasing Lamplighters Hebrew Academy of all such liability, including that caused by negligence. In case of an emergency, I give permission for my child to receive medical treatment. In case of such an emergency, please contact (name of parent or guardian): Emergency Phone Number: Parent/Guardian Signature: (By entering your name in the box below, you are effectively providing your signature, indicating that all the information on this form is true and accurate, to the best of your knowledge.) Total $0.00 Payment Credit Card Cash or Check Credit Card We accept Visa, MasterCard, American Express, Discover Credit Card Number Security Code Name on Card1 - January2 - February3 - March4 - April5 - May6 - June7 - July8 - August9 - September10 - October11 - November12 - December Expiration Month2024202520262027202820292030203120322033 Expiration YearChecks Should be mailed to: Chabad of Charlotte County, 424 W Henry Street Punta Gorda, FL 33950Billing Address Street Address City State / Province Postal / Zip CodePlease SelectUnited StatesAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanThe BahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChilePeople's Republic of ChinaRepublic of ChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCook IslandsCosta RicaCote d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonThe GambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern MarianaNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint BarthelemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSomalilandSouth AfricaSouth OssetiaSpainSri LankaSudanSurinameSvalbardSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTristan da CunhaTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamBritish Virgin IslandsUS Virgin IslandsWallis and FutunaWestern SaharaYemenZambiaZimbabweOther Country Submit I would like to receive news and updates by email Should be Empty: This page uses TLS encryption to keep your data secure.
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