Registration - JewishEC.com

Bat Mitzvah Club Registration
Please fill out this form as an initial registration for Bat Mitzvah Club.
Confirmation of acceptance will be acknowledged only after this registration form is reviewed and an acceptance letter is received.
Child's Name:*
First Name Last Name
Hebrew Name:*
Birth Date:*

Month Day Year
School:*
Previous Jewish Education:*
Grade Entering:*
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.*
Parents Information
Father's Name:*
First Name Last Name
Father's Cell:*

Area Code Phone Number
Mother's Name:*
First Name Last Name
Mother's Cell:*

Area Code Phone Number
E-mail*
As the parent(s) or legal guardian of the above child, I/we authorize any adult acting on behalf of Chabad to hospitalize or secure treatment for my child, I further agree to pay all charges for that care and/or treatment. It is understood that if time and circumstances reasonably permit, Chabad personnel will try, but are not required, to communicate with me prior to such treatment. I hereby give permission for my child to participate in all activities, join in club trips on and beyond Chabad properties and allow my child to be photographed while participating in Chabad activities.
*

Yes, I accept
Payment
Registration:

$250

Payment*

Credit Card Paypal Check

Postal / Zip Code

Country

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Bat Mitzvah Club