Post Bar/Bat Mitzvah Program

Address*

Phone Number*

Area Code Phone Number
Father's Full Name*

First Name Last Name
Father's Cell Phone Number*

Area Code Phone Number
Father's E-mail:*
Mother's Full Name*

First Name Last Name
Mother's Cell Phone Number*

Area Code Phone Number
Mother's E-mail:
Is the child's mother born Jewish?*

Yes No
Mother's Hebrew Name:*
Are there any adoptions in the family?*

Yes No
Are there any conversions in the family?*

Yes No
If you answered yes to either one please specify:
About your child
Does your child read basic Hebrew?*

Yes No
Previous religious school education*
Does your child have any learning difficulties with general studies?*

Yes No
Please explain:
Any behavioral information we should be aware of?*
Emergency Information
Emergency Contact 1*

First Name Last Name
Phone Number*

Area Code Phone Number
Emergency Contact 2

First Name Last Name
Phone Number

Area Code Phone Number
Medication child is taking on a regular basis*
Any special medical circumstances or allergies*
Tuition & Payment Options:
CTeen Junior takes place on Sunday Mornings 10:15-11:45
$600 Tuition
Payment Options:*

Pay in Full: $600 2 Equal Payments: $300 4 Equal Payments: $150
Amount to charge my card today:*

$
Total:

$0.00

Payment

Credit Card

Billing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

*

I authorize the Chabad staff to take my child on class trips (you will be notified prior to any trips). I authorize Chabad staff to take pictures / videos of my child and be able to use them for publicity purpose In the event I can not be reached I hearby grant permission to the Chabad staff to treat and or provide a physician or hospital to give emergency treatment to my child.
Signature*
Date*

Month Day Year
Should be Empty:

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