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Children & Youth Jewish Homeschool Coop

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Child's Information
Child's Name*
First NameLast Name
Hebrew Name*
Date of Birth*
MonthDayYear
Gender

Address*

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

Home Phone*
Area CodePhone Number
Mother's Cell Phone*
Area CodePhone Number
Father's Cell Phone*
Area CodePhone Number
Primary E-mail Contact
Mother's Information
Name*
First NameLast Name
Hebrew Name
Jewish by:*
BirthChoice
Occupation
Name of Business

Business Address*

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

Business Phone*
Area CodePhone Number
E-mail
Father's Information
Name*
First NameLast Name
Hebrew Name
Jewish by:*
BirthChoice
Occupation
Name of Business

Business Address*

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

Business Phone*
Area CodePhone Number
E-mail
About your child
What is your child's nickname
Was your child's birth premature*
YesNo
Were there any problems with infancy, physical development, etc.?*
YesNo
If yes, please explain
Has your child ever been hospitalized or had a serious illness?*
YesNo
If yes, please explain
Does your child take any medication regularly*
YesNo
If yes, please explain
Does your child have any allergies*
YesNo
If yes, please explain
Does your child have any food restrictions?*
YesNo
If yes, please explain
Does your child nap?*
YesNo
What time does your child go to sleep for the night and wake up in the morning?
Is your child fully toilet trained?*
YesNo
Does he/she need a reminder to go to the bathroom? Please explain
Does your child dress himself/herself at home?
YesNo
What is the primary language spoken at home?
What other language is your child exposed to?
Does your child speak in
WordsSentences
How does your child show his/her feelings?
What makes your child angry or upset?
Is your child frightened by
AnimalsDarkStormsLoud noisesClownsOther
Please specify
What do you find is the best way of handling your child when he/she is upset?
What particular play activities does your child enjoy and have a special interest in?
What particular activity does your child NOT enjoy?
Does your child have any physcial or emotional conditions that the staff should be aware of?
Is your child currently receiving therapy or services ?
Does your child live with both parents?*
YesNo
Explain if necessary
Do you have talents, hobbies, etc., that you would be willing to share with or demonstrate for the children in Homeschool Coop?
Grandparents Names

Address

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

Grandparents Names

Address

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

Is your child adopted?*
YesNo
Has anyone in the immediate family been adopted or converted?*
YesNo
If yes, please explain
Congregation of family's affiliation (if applicable)
Picture Permission
I give permission for my child's picture to be used for display and public relations purposes. Please type your name and date.
Picture Permission*
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Date*
MonthDayYear
Day Options
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If your child is attending part time, please specify the hours
Tuition policy
Fees: $10 per hour to be paid on the last day of the month. Checks can be made out to Chabad Center, 34 Cedar Street, Milford, MA 01757
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