Post Bar/Bat Mitzvah Program

Student's Full Name*

First NameLast Name

Student's Hebrew Name*

Gender*

FemaleMale

Birth Date*

MonthDayYear

Grade Entering:*

7th8th

School*

Address*

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Phone Number*

Area CodePhone Number

Father's Full Name*

First NameLast Name

Father's Cell Phone Number*

Area CodePhone Number

Father's E-mail:*

Mother's Full Name*

First NameLast Name

Mother's Cell Phone Number*

Area CodePhone Number

Mother's E-mail:

Is the child's mother born Jewish?*

YesNo

Mother's Hebrew Name:*

Are there any adoptions in the family?*

YesNo

Are there any conversions in the family?*

YesNo

If you answered yes to either one please specify:

Does your child read basic Hebrew?*

YesNo

Previous religious school education*

Does your child have any learning difficulties with general studies?*

YesNo

Please explain:

Any behavioral information we should be aware of?*

Emergency Contact 1*

First NameLast Name

Phone Number*

Area CodePhone Number

Emergency Contact 2

First NameLast Name

Phone Number

Area CodePhone Number

Medication child is taking on a regular basis*

Any special medical circumstances or allergies*

CTeen Junior takes place on Sunday Mornings 10:15-11:45
$600 Tuition

Payment Options:*

Pay in Full: $6002 Equal Payments: $3004 Equal Payments: $150

Amount to charge my card today:*

$

Total:

$0.00

Payment

Credit Card

Credit Card Type
Credit Card Number	Security Code
Name on Card
Expiration Month	Expiration Year

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 purposeIn 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*

MonthDayYear

Basic Information

About your child

Emergency Information

Tuition & Payment Options:

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