| REGISTRATION 201-12 UNITED HEBREW SCHOOL
7255 Granby Street Norfolk, 23505 FAX- 757 489-3425
Student’s name _______________________________________________________
Synagogue affiliation (circle one)
Beth El KBH Temple Emanuel Temple Israel
Enrolling in Hebrew class (please circle one)
2nd grade-Pre-reading 3rd grade-Alef 4th grade-Bet 5th grade-Gimel 6th grade-Dalet
Address ________________________________________________________
City__________________________/ State ____ ____/ Zip______________
Email addresses ____________________________________@_________________
____________________________________@________________
Parents’ names _____________________________________________________
Evening phone # _________________________________ Sunday morning phone # _____________________________
Wednesday afternoon phone # ________________________ Other phone # _____________________________________
If parents are not reachable, in an emergency whom can we call? __________________________________________________________________
Allergies or health concerns, or academic information that will help us serve your child better. (All such information is kept confidential)
_____________________________________________________________________
Hebrew name________________________________________ Birthdate ___ ____/____ _____/ ____ ____ ____ ____
Name of weekday school ___________________________________________________________
Comments___________________________________________________________________________
Registration is contingent upon parental consent for UHS staff to render first aide in case of emergency, and permission to take and use photos of the student for UHS files, and for use in synagogue, UHS web site and UHS and Federation news items--without identifying any individual children.
___________________________________________________/___________________ Parent's signature date
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