Sign Up - Chabad of the Beaches

Full Name

First NameLast Name

Hebrew Name

Birth Date

MonthDayYear

School

Grade Entering*

Bat Mitzvah Dateif known

MonthDayYear

Address

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

Email

Father's Name

Father's Cell

Area CodePhone Number

Mother's Name

Mother's Cell

Area CodePhone Number

Emergency Contact 1

First NameLast Name

Phone Number

Area CodePhone Number

Emergency Contact 2

First NameLast Name

Phone Number

Area CodePhone Number

Doctor's Name

First NameLast Name

Phone Number

Area CodePhone Number

CONFIDENTIAL: If your child has any allergies or other medical condition we should be aware of please describe them and indicate special precautions or care needed.

Parental Authorization

As the parent(s) or legal guardian of the above child, I/we authorize any adult acting on behalf of Chabad of the Beaches 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 of the Beaches 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 school activities, join in class and school trips on and beyond school properties and allow my child to be photographed while participating in all activities and that these pictures may be used for marketing purposes.

Cost for the year $72

$0.00

Payment

Credit Card Pay Later

Postal / Zip Code

Country

Bat Mitzvah Club