HS Registeration - JRCC.org

Register your child to the JRCC Rockford
Hebrew School for 2020-2021

To return to the Hebrew School Website,Click Here.
| Childs Information
Full Name*

First Name Last Name
Hebrew Name*

First Name
Entering Grade*
Date of Birth*

Month Day Year
| Parents Information
Father
Name*

First Name Last Name
Occupation
E-mail*
Cell Phone*

Area Code Phone Number
Mother
Name*

First Name Last Name
Occupation
E-mail*
Cell Phone*

Area Code Phone Number

Address*

Is the child's biological mother Jewish by birth?*

yes no
Is the child's biological father Jewish by birth?*

yes no
Have there been any conversions or adoptions in your family?*

yes no
| Medical Information
Family physician*
Is there any medical or other information (allergies, etc.) regarding your child that our school should be aware of?*
Medical Release Form:

As the parent(s) or legal guardian of the above child, I/we authorize any adult acting on behalf of JRCC Hebrew School to hospitalize or secure treatment for my/our child in the event of an emergency, I/we further agree to pay all charges for that care and/or treatment. It is understood that if time and circumstances reasonably permit, JRCC Hebrew School personnel will try, but are not required, to communicate with me/us prior to such treatment.
Signature of parent or guardian:
Type your name as a signature*
Date*
| Payment
Total payment amount*

Payment*

Credit Card Cheque

Postal / Zip Code

Country

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