Enrolment Form - ChabadHouse.org.au

How many children would you like to enrol*
CHILD 1
CHILD INFORMATION
Full Name*

First Name Last Name
Hebrew School day of the week* Please select the day of the week you would like to enrol your child into Chabad Hebrew School

WednesdayThursday
Gender*

MaleFemale
Hebrew Name*
Primary Language
Date of Birth*

Day Month Year
School Attending
School Year (2024)*
Child Primarily lives with

Primary Parent/GuardianSecondary Parent/Guardian
Previous Jewish Education
Hebrew Reading

NoneSomewhatWell
Is the natural mother of the child Jewish?*

YESNO
Have there been any conversions or adoptions in the family?*

YESNO
CCS (Child Care Subsidy) Details
(this is required to receive government subsidies)
Full Legal Name of Child*

First Name Last Name
CRN Number*
AUTHORISATION
I agree that if my child has been injured, or becomes ill whilst at the service or otherwise in care, for the approved provider, a nominated supervisor or an educator to seek: Medical treatment for the child from a registered medical practitioner, hospital or ambulance service and transportation of the child by an ambulance service*

YESNO
I give consent to the carrying out of appropriate medical, dental or hospital treatment*

YESNO
Does your child have any special considerations we need to take into account for their enrolment?*

YESNO
If Yes, please advise of the special considerations.
MEDICAL CONDITION & DIETARY RESTRICTION
Does your child have any medical management plan, anaphylaxis medical management plan or risk minimisation plan with respect to the child's healthcare need, medical condition or allergy?*

YESNO
If yes, you MUST email a colour copy of your child’s Action Plan to [email protected] and ensure they bring their medication on each day.
Does your child have a diagnosed disability?*

YESNO
If Yes, please advise of the diagnosed disability.
ADDITIONAL INFORMATION
Please provide any information you feel the service should know about the child e.g. language, religion, court orders, additional needs etc.
CHILD 2
CHILD INFORMATION
Full Name*

First Name Last Name
Hebrew School day of the week* Please select the day of the week you would like to enrol your child into Chabad Hebrew School

WednesdayThursday
Gender*

MaleFemale
Hebrew Name*
Primary Language
Date of Birth*

Day Month Year
School Attending
School Year (2024)*
Child Primarily lives with

Primary Parent/GuardianSecondary Parent/Guardian
Previous Jewish Education
Hebrew Reading

NoneSomewhatWell
Is the natural mother of the child Jewish?*

YESNO
Have there been any conversions or adoptions in the family?*

YESNO
CCS (Child Care Subsidy) Details
(this is required to receive government subsidies)
Full Legal Name of Child*

First Name Last Name
CRN Number*
AUTHORISATION
I agree that if my child has been injured, or becomes ill whilst at the service or otherwise in care, for the approved provider, a nominated supervisor or an educator to seek: Medical treatment for the child from a registered medical practitioner, hospital or ambulance service and transportation of the child by an ambulance service*

YESNO
I give consent to the carrying out of appropriate medical, dental or hospital treatment*

YESNO
Does your child have any special considerations we need to take into account for their enrolment?*

YESNO
If Yes, please advise of the special considerations.
MEDICAL CONDITION & DIETARY RESTRICTION
Does your child have any medical management plan, anaphylaxis medical management plan or risk minimisation plan with respect to the child's healthcare need, medical condition or allergy?*

YESNO
If yes, you MUST email a colour copy of your child’s Action Plan to [email protected] and ensure they bring their medication on each day.
Does your child have a diagnosed disability?*

YESNO
If Yes, please advise of the diagnosed disability.
ADDITIONAL INFORMATION
Please provide any information you feel the service should know about the child e.g. language, religion, court orders, additional needs etc.
CHILD 3
CHILD INFORMATION
Full Name*

First Name Last Name
Hebrew School day of the week* Please select the day of the week you would like to enrol your child into Chabad Hebrew School

WednesdayThursday
Gender*

MaleFemale
Hebrew Name*
Primary Language
Date of Birth*

Day Month Year
School Attending
School Year (2024)*
Child Primarily lives with

Primary Parent/GuardianSecondary Parent/Guardian
Previous Jewish Education
Hebrew Reading

NoneSomewhatWell
Is the natural mother of the child Jewish?*

YESNO
Have there been any conversions or adoptions in the family?*

YESNO
CCS (Child Care Subsidy) Details
(this is required to receive government subsidies)
Full Legal Name of Child*

First Name Last Name
CRN Number*
AUTHORISATION
I agree that if my child has been injured, or becomes ill whilst at the service or otherwise in care, for the approved provider, a nominated supervisor or an educator to seek: Medical treatment for the child from a registered medical practitioner, hospital or ambulance service and transportation of the child by an ambulance service*

YESNO
I give consent to the carrying out of appropriate medical, dental or hospital treatment*

YESNO
Does your child have any special considerations we need to take into account for their enrolment?*

YESNO
If Yes, please advise of the special considerations.
MEDICAL CONDITION & DIETARY RESTRICTION
Does your child have any medical management plan, anaphylaxis medical management plan or risk minimisation plan with respect to the child's healthcare need, medical condition or allergy?*

YESNO
If yes, you MUST email a colour copy of your child’s Action Plan to [email protected] and ensure they bring their medication on each day.
Does your child have a diagnosed disability?*

YESNO
If Yes, please advise of the diagnosed disability.
ADDITIONAL INFORMATION
Please provide any information you feel the service should know about the child e.g. language, religion, court orders, additional needs etc.
PARENTS/GUARDIAN DETAILS

PRIMARY PARENT/GUARDIAN
(This person's details are used to claim government subsidy)
Full Name*

First Name Last Name
Relation to child*
E-mail *
Phone (Mobile)*
Phone (Home)

Address*

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

Authorisation*

CollectionExcursionEmergencyMedicalTransportationAllow Sign In / OutAllow Confirm In / Out
CCS (Child Care Subsidy) Details
(this is required to receive government subsidies)
Full Legal Name of Parent Registered for CCS*

First Name Last Name
Date of Birth*

Day Month Year
CRN Number*
SECONDARY PARENT/GUARDIAN
Full Name*

First Name Last Name
Relation to child*
E-mail*
Phone (Mobile)*
Phone (Home)

Address*

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

Authorisation*

CollectionExcursionEmergencyMedicalTransportationAllow Sign In / OutAllow Confirm In / Out
ADDITIONAL/EMERGENCY CONTACTS

(Minimum 2 required)

Please enter additional contacts for this enrolment. This may include emergency contacts when you are unavailable to be contacted in the case of an emergency. E.g for medical authorisations, to authorise staff to remove the child form the facility or for any other emergencies. This may also include authorised nominees who may drop off or pick up this child or authorise excursions.
ADDITIONAL/EMERGENCY CONTACT 1
Full Name*

First Name Last Name
Relation to child*
E-mail*
Phone (Mobile)*
Phone (Home)

Address*

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

Authorisation*

CollectionExcursionEmergencyMedicalTransportationAllow Sign In / OutAllow Confirm In / Out
ADDITIONAL/EMERGENCY CONTACT 2
Full Name*

First Name Last Name
Relation to Child*
E-mail*
Phone (Mobile)*
Phone (Home)

Address*

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

Authorisation*

CollectionExcursionEmergencyMedicalTransportationAllow Sign In / OutAllow Confirm In / Out
MEDICAL CONTACTS

Please enter your child's Doctors information. You should enter medical contact here.
Doctor or Practice Name*

First Name Last Name or practice name
Relation to child*
E-mail
Phone (Work)*
Phone (Mobile)

Address*

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

Authorisation*

EmergencyMedical
IMMUNISATIONS
The service needs to sight your child's Immunisation history statement.

Please email [email protected] with your child’s Medicare Immunisation form.
CHILD CARE SUBSIDY (CCS) ENROLMENT AGREEMENT

As a part of your enrolment at our service we require you to confirm acceptance of the following items in order to be eligible to receive Government funding if available. Acceptance of these items as well as some of the other information in the enrolment form can be used as a Complying Written Arrangement. Please read these items and confirm your acceptance of these items, by signing below.

·  I confirm that my details in this enrolment form as well as the details of the child I am enrolling are correct.

·  I confirm I have agreed to days of care with this service and understand the start and end times of the care provided.

·  I confirm that care may be provided on a casual or flexible basis where available at my service(s) at my request.

·  I confirm I understand the usual fees associated with the care of my child which may vary from time to time.

Chabad Hebrew School Enrolment Agreement

By signing below, I confirm,

I indemnify Chabad North Shore against responsibility for any accident, loss or injury suffered by my child/ren during the course of the activities.

I expressly release Chabad North Shore, its employees or officers from any claim or liability arising directly or indirectly from the enrolled program.

That my child will be photographed and videoed for the purposes of recording the wonderful services we offer, and sharing this information with our parent-body, and for encouraging the attendance of others within our community. If you specifically do not want pictures of video clips of your child/ren shared, please contact Chanie Schapiro - [email protected] to discuss.
Sign by filling-in your full Legal Name*
DOCUMENTATION

Please bring-in your original Ketubah (Jewish marriage certificate) and your child’s birth certificate.
PAYMENT INFORMATION

A deposit of $100 per child is taken within 2 days of confirmation of this enrolment. The money will go towards the next term's fees. Payment is charged based on the payment plans you choose below. If CCS has not been confirmed before than, you will be charged regular rates at the first billing cycle, and once CCS is confirmed, the balance will be credited to your account for future billing cycles.

Click here for the class rates.
Click here for more information about CCS.
Payment Options*

Pay in full today for 2024Pay by term, at the first Monday of each termPay by half term, at the first and fifth Monday of each term
Payment Method*

Direct DebitCredit Card (Surcharge of 1.1% Mastercard, 1.5% VIsa and 2% Amex)

Credit Card

We accept Visa, MasterCard, American Express
Credit Card Number
Expiration Month	Expiration Year

Bank:*
Account Name:*
BSB:*
Account Number:*
Should be Empty:

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