Please note that registration does not confirm your spot. An email will go out with confirmation. Your credit card WILL NOT be charged without prior authorization from you after confirmation. For now the credit card you input comes in to us as an email and nothing more. CHILD 1Full Name*First NameLast NameWhat would you like your child to be called?Hebrew NameBirth Date1 - January2 - February3 - March4 - April5 - May6 - June7 - July8 - August9 - September10 - October11 - November12 - DecemberMonth12345678910111213141516171819202122232425262728293031Day20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920YearHebrew BirthdayGenderMaleFemaleChild 1 Primary Address*Street AddressStreet Address Line 2CityState / ProvincePostal / Zip CodePlease SelectUnited StatesAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanThe BahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChilePeople's Republic of ChinaRepublic of ChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCook IslandsCosta RicaCote d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonThe GambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern MarianaNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint BarthelemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSomalilandSouth AfricaSouth OssetiaSpainSri LankaSudanSurinameSvalbardSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTristan da CunhaTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamBritish Virgin IslandsUS Virgin IslandsWallis and FutunaWestern SaharaYemenZambiaZimbabweOtherCountryChild resides with:Both ParentsMomDadGuardianEMERGENCY CONTACTFirst NameLast NameEmergency Contact Phone NumberArea CodePhone NumberPlease check off which program you wish to enroll your child in:Baby Room – (6 weeks-1 Years old) 8:30-3:30 – 5 Full daysBaby Room – 4 hours 8:30-12:30 (Different hours can be arranged if needed)EC 1 - (Child must be One by September 1st) 8:30- 3:30 Friday 2:20EC 2 - (Child must be 2 by September 1st) 8:30- 3:30 Friday 2:20EC 3 (Child must be 3 by September 1st) 8:30-3:30 Friday 2:20EC 4 (Child must be 4 by September 1st) 8:30-3:30 Friday 2:20• Please note that there are certain criteria that must be met in order for your child to go into the 3 Year old class.Does your child have any allergies or medical problems?YesNoAre there any conditions or behavior that require special attention, medication or a special diet?YesNoHas your child ever been hospitalized or had a serious illness?YesNoHas your child ever been evaluated for developmental delays or has an evaluation been recommended in the past?YesNoAdditional notable InformationPlease let us know if there are any allergies or other important information we need to be aware of.CHILD 2Full NameFirst NameLast NameWhat would you like your child to be called?Hebrew NameBirth Date1 - January2 - February3 - March4 - April5 - May6 - June7 - July8 - August9 - September10 - October11 - November12 - DecemberMonth12345678910111213141516171819202122232425262728293031Day20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920YearHebrew BirthdayGenderMaleFemaleChild 2 Primary AddressStreet AddressStreet Address Line 2CityState / ProvincePostal / Zip CodePlease SelectUnited StatesAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanThe BahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChilePeople's Republic of ChinaRepublic of ChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCook IslandsCosta RicaCote d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonThe GambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern MarianaNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint BarthelemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSomalilandSouth AfricaSouth OssetiaSpainSri LankaSudanSurinameSvalbardSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTristan da CunhaTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamBritish Virgin IslandsUS Virgin IslandsWallis and FutunaWestern SaharaYemenZambiaZimbabweOtherCountryChild resides with:Both ParentsMomDadGuardianPlease check off which program you wish to enroll your child in:Baby Room – (6 weeks-1 Years old) 8:30-3:30 – 5 Full daysBaby Room – 4 hours 8:30-12:30 (Different hours can be arranged if needed)EC 1 - (Child must be One by September 1st) 8:30- 3:30 Friday 2:20EC 2 - (Child must be 2 by September 1st) 8:30- 3:30 Friday 2:20EC 3 (Child must be 3 by September 1st) 8:30-3:30 Friday 2:20EC 4 (Child must be 4 by September 1st) 8:30-3:30 Friday 2:20• Please note that there are certain criteria that must be met in order for your child to go into the 3 Year old class.Does your child have any allergies or medical problems?YesNoAre there any conditions or behavior that require special attention, medication or a special diet?YesNoHas your child ever been hospitalized or had a serious illness?YesNoHas your child ever been evaluated for developmental delays or has an evaluation been recommended in the past?YesNoAdditional notable InformationPlease let us know if there are any allergies or other important information we need to be aware of.CHILD 3Full NameFirst NameLast NameWhat would you like your child to be called?Hebrew NameBirth Date1 - January2 - February3 - March4 - April5 - May6 - June7 - July8 - August9 - September10 - October11 - November12 - DecemberMonth12345678910111213141516171819202122232425262728293031Day20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920YearHebrew BirthdayGenderMaleFemaleChild resides with:Both ParentsMomDadGuardianPlease check off which program you wish to enroll your child in:Baby Room – (6 weeks-1 Years old) 8:30-3:30 – 5 Full daysBaby Room – 4 hours 8:30-12:30 (Different hours can be arranged if needed)EC 1 - (Child must be One by September 1st) 8:30- 3:30 Friday 2:20EC 2 - (Child must be 2 by September 1st) 8:30- 3:30 Friday 2:20EC 3 (Child must be 3 by September 1st) 8:30-3:30 Friday 2:20EC 4 (Child must be 4 by September 1st) 8:30-3:30 Friday 2:20• Please note that there are certain criteria that must be met in order for your child to go into the 3 Year old class.Does your child have any allergies or medical problems?YesNoAre there any conditions or behavior that require special attention, medication or a special diet?YesNoHas your child ever been hospitalized or had a serious illness?YesNoHas your child ever been evaluated for developmental delays or has an evaluation been recommended in the past?YesNoAdditional notable InformationPlease let us know if there are any allergies or other important information we need to be aware of.PARENTS INFORMATIONFather's Name*First NameLast NameFather's Cell*Area CodePhone NumberFather's E-mailMother's Name*First NameLast NameMother's Hebrew NameMother's Cell*Area CodePhone NumberMother's E-mailRegistration Process & Policies • This registration form must be completed and signed for each student. The non –refundable registration fee must accompany this form in order to secure placement. • School registrants must be in good standing financially with the Emery & Mimi Green Chabad Preschool. • Students whose tuition is in arrears will not be permitted to return to school until your account is made current. The Chabad Preschool reserves the right to cancel the enrollment of any student for non-payment. A $35 fee will be assessed for returned checks. • Upon receipt of this registration form, a space is reserved for your child. You should also have received a packet of all necessary required forms. Children will be admitted into class when we have received all required forms and your child’s file is complete and current, pursuant to DCF & NAEYC regulations. • The Chabad Preschool reserves the right to cancel students’ enrollment or dismiss any student/family whose conduct, influence and/or behavior is deemed unsatisfactory and not in the best interest of the school or Synagogue. • Once month’s written advance notice is required to withdraw a child from the program without financial penalty. • There is no tuition adjustments or credit given for holidays, family vacations or illness. • Children are placed in classes at the discretion of the school Signiture*SignaturePerson (s) Responsible for billing:BothMomDadGuardianStudent Registration Fee: $300.00 (Due upon registration) Security Fee- $500 per child (due upon registration) INFANT ROOM - $11000 Five full Days 8:30 am-3:20 pm (Friday 2:20 pm) , $7500 half day YOUNG TODDLERS - $10700 Five full Days 8:30 am-3:20 pm (Friday 2:20 pm) EARLY CHILDHOOD 2 - $ 10700 Five full Days 8:30 am-3:20 pm (Friday 2:20 pm) Early Childhood 3 - $ 10700 Five full Days 8:30 am-3:20 pm (Friday 2:20 pm) Early Childhood 4 $8700 withVPK $10,700 withoutVPK Five full Days 8:30 am-3:20 pm (Friday 2:30 pm) Pre –care & After –carePre Care - 8:00-8:30 AM $10 per day after Care- 3:30- 5:00 pm $10 per day NO AFTERCARE ON FRIDAYPAYMENTRegistration & Security Fee*1 Child2 Children3 ChildrenI hereby authorize the Emery & Mimi Green Chabad Preschool to charge my credit card on the first day of each month. If the first day of the month falls on a non-business day, the card will be debited on the last day prior to the 1rst. I understand that it is my responsibility to notify the Chabad Preschool when/if the card is no longer valid and to provide a different form of payment.Total$0.00Payment*Credit Card Check Credit CardWe accept Visa, MasterCard, American Express, DiscoverCredit Card NumberSecurity CodeName on Card1 - January2 - February3 - March4 - April5 - May6 - June7 - July8 - August9 - September10 - October11 - November12 - DecemberExpiration Month2023202420252026202720282029203020312032Expiration YearBilling AddressStreet AddressStreet Address Line 2CityState / ProvincePostal / Zip CodePlease SelectUnited StatesAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanThe BahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChilePeople's Republic of ChinaRepublic of ChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCook IslandsCosta RicaCote d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonThe GambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern MarianaNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint BarthelemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSomalilandSouth AfricaSouth OssetiaSpainSri LankaSudanSurinameSvalbardSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTristan da CunhaTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamBritish Virgin IslandsUS Virgin IslandsWallis and FutunaWestern SaharaYemenZambiaZimbabweOtherCountryI will turn in to the Chabad Preschool postdated checks with my tuition agreement for the amount of anticipated months my child will be enrolled.HOURS OF OPERATIONThe Emery & Mimi Green Chabad Preschool is open Monday through Friday. Our program hours are from 8:30 am to 3:30 p.m. with extended care offered from 8:00 a.m. until 5:00 pm. Please be prompt. At the end of the month, a $10 an hour late fee will automatically be charged for arrival after your designated pick up time.I agree*YesALTERNATIVE NUTRITIONI understand and approve the use of the Alternate Nutrition plan. I agree to provide the following meals and/or snacks to meet my child’s nutritional and dietary needs. Parent: Breakfast Parent: AM Snack Parent: Noon Meal Parent: PM SnackI agree*YesDISCIPLINE POLICYDiscipline at The Emery & Mimi Green Chabad Preschool will take the form of positive classroom management. Emphasis is placed on the behavior and not the individual child. Our goal is for the child to learn self-management skills and inner control - participation in a safe, loving and well planned environment. Children are provided with consistent routines and realistic limits and expectations. Children shall not be subjected to discipline which is severe, humiliating or frightening. Discipline shall not be associated with food, rest or toileting. Spanking or any form of physical punishment is prohibited. The The Emery & Mimi Green Chabad Preschool will do our best to provide proper placement of each child. Unfortunately, there are sometimes reasons we have to expel a child from our program either on a short term or permanent basis. This can be as a result of physically harmful behaviors or the like. Prior to expulsion, a parent will be called and correspondence will be sent home indicating what the problem is, and every effort will be made by both the center and the parent to correct the problem. (To see more, read the Parent's Handbook.)I agree*YesKNOW YOUR CHILD CARE FACILITYView KNOW YOUR CHILD CARE FACILITYI agree*I have received a copy of KNOW YOUR CHILD CARE FACILITYPERMISSION TO PHOTOGRAPHI agree*I hereby give The Emery & Mimi Green Chabad Preschool permission to photograph and videotape my child during the school year.PHONE LISTI agree*I give permission for our name and telephone number to be placed on a class list for release to other parents.OUTSIDE FOOD POLICYMy child may participate in birthday parties, holiday programs, and any other activities/ programming in which special food is served from outside or prepared in school.I understand*YesPHYSICAL ACTIVITYYour child will partake in indoor and outdoor physical activity during the course of the day. The children enjoy obstacle courses, balancing equipment, ball play, bicycles and the play structure for at least 40 minutes per day for half day students and 40 minutes twice daily for full day students. Please send your child to school with appropriate clothing for the weather, such as sweaters or rain gear. Children are to wear closed toe, supportive shoes. No flip flops or open back shoes allowed. When we experience inclement weather, we will partake in indoor gross motor play in our multi purpose room. Children will be encouraged, but never forced, to participate in the physical activitiesI understand*YesPARENT HANDBOOKView Parent HandbookI agree*I have read the Parent Handbook. I understand and agree to all its content.REQUIRED FORMSThe following forms need to be submitted to finalize your enrollment. Forms should be emailed to [email protected] . Your child will be fully registered and a spot will be secured only when all documents and tuition contract have been received and approved by our office. Tuition contracts will be emailed to you after registration is submitted. Influenza FormCopy of Child's Birth CertificateSchool Medical Forms (your FLORIDA pediatrician will provide these)School Immunization Forms (your FLORIDA pediatrician will provide these VPK Eligibility Certificate this is mandatory for all children turning 4 before September 1, 2021Safe Sleep Policy for Infant class onlyDistracted AdultCovid-19 WaiverEmergency Contact I agree*I hereby grant permission for the staff of this facility to have access to my child's recordsI have read the above information and I understand and consent to all the aforementioned. Parent’s Signature*Comments/NotesSubmitShould be Empty: This page uses TLS encryption to keep your data secure.