Chai Five Registration 2023-24

* Student First Name

* Student Last Name

* Address

* City

* State

* Zip

* Student Cell Phone Number

* Student Email Address

* Student Date of Birth

* Student Grade

* School Name

* Class Enrolling In

If you are in need of financial assistance,
please contact Rabbi Adler.

* Parent/Guardian First Name

* Parent/Guardian Last Name

* Parent/Guardian Cell Phone Number

* Parent/Guardian Email Address

Please send Chai Five communications to this email address

* If there is a second parent/guardian, please select Yes.

Please Select OneYesNo

Parent/Guardian 2 First Name

Parent/Guardian 2 Last Name

Parent/Guardian 2 Cell Phone Number

Parent/Guardian 2 Email Address

Please send Chai Five communications to this email address

EMERGENCY MEDICAL AUTHORIZATION
Should my child suffer an injury or illness while in the care of Etz Chaim Religious School and the facility is unable to contact me (us) immediately, it shall be authorized to secure such medical attention and care as may be necessary.
I (We) shall assume responsibility for payment for services.

My child will be transported to Children’s Healthcare of Atlanta at Scottish Rite.

* Please type your name here as your signature and acknowledgement of the emergency medical authorization

2nd Parent/Guardian (if applicable) - Please type your name here as your signature and acknowledgement of the emergency medical authorization

TOTAL

Sun, October 1 2023 16 Tishrei 5784



kROGER pURCHASES BENEFIT eTZ cHAIM
1190 INDIAN HILLS PARKWAY MARIETTA, GA 30068 MAIN: 770.973.0137 \| EDUCATION: 770.977.3384 FAX: 770.977.0829 REFUND POLICY: FOR BILLING DISCREPANCIES OR QUESTIONS, PLEASE CALL