Registration Form

Date of Registration  


I. Child's Information:




Parent Information:

  II. Medical Information:

Family Doctor:


Doctor's Office Phone: 

Are there any Allergies or Medical Problems:

Are there any conditions or behaviors that require special attention, medication?

Has your child had any history of communicable diseases or requiring special attention?

Please give details concerning any special requirements relating to diet, rest or exercise. 


Emergency Alternate Contacts 

                     Name                     Phone             Address                        Relationship 
Emergency 1    

Emergency 2    

Name of Person to whom my child can be released:


If an emergency arises (G‑d forbid), and none of the people mentioned above can be contacted, I hereby give Chabad Daycare permission to take whatever measure it feels proper and safe considering the circumstances. 

Please advise that I give my full consent to the faculty of Chabad Daycare to take my child for short walks to local parks/libraries and the like outside the daycare facilities at any time they deem appropriate.

 By clicking this box I show my consent to the above and print my name below.


I have read all the policies and procedures concerning Chabad Daycare. Download Here



Payment Information

Registration Fee

Card Type

Card Number

Expiration Date

Security Code

Name on Card

Billing address

Billing Postal code