Hebrew Reading Room - Chabad of Northeast Portland

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Additional notable Information
Parents Information
Father's Name*
First NameLast Name
Father Cell
Area CodePhone Number
Mother's Name*
First NameLast Name
Mother Cell
Area CodePhone Number
Emergency Medical Information
Emergency contact 1:*
First NameLast Name
Relationship to child:*
Phone Number*
Area CodePhone Number
Emergency contact 2:
First NameLast Name
Relationship to child:
Phone Number
Area CodePhone Number
Physician's name:*
First NameLast Name
Physician's phone number:*
Area CodePhone Number
CONFIDENTIAL: Does your child have any allergies or other medical condition we should be aware of? If yes, please describe them and indicate special precautions or care needed.*
Payment
My child will be attending:*
Total
$0.00

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Hebrew Reading Room Registration