Registration - Chabad of Great Neck

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Child 1

Full Name*

First NameLast Name

Hebew Name*

Birth Date*

MonthDayYear

Age*

School Entering*

Grade Entering*

Child 2

Full Name

First NameLast Name

Hebew Name

Birth Date

MonthDayYear

Age

Grade Entering

School Entering

Child 3

Full Name

First NameLast Name

Hebew Name

Birth Date

MonthDayYear

Age

School Entering

Grade Entering

Parents Information

Address*

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

Mother's Information

*

Mother's Full Name
Mother's Email
Mother's Cell Number	Mother's Work Number
Mother's Hebrew Name	Country

Father's Information

Father's Full Name
Father's Email
Father's Cell Number	Father's Work Number
Father's Hebrew Name	Country

Emergency Contact

Contact 1*

Name
Address
Cell Number	Home Number
Relationship	Country

To enhance our curriculum we have school events and programs.

Would you be willing to assist in even planning?

YesNo

Would you like to be a class mother?

YesNo

I hereby permit my child to participate in all activities, join in class and school trips on and beyond school properties. In case of an emergency, I herby authorize the school to have my child taken care of by a physician in any way that the situation may call for.

Signature of Parent/Guardian: (Please enter your email address)*

Date*

MonthDayYear

Payment Options

PRICE:
Bar & Bat Mitzvah (6th and 7th Grade - Sundays) $1200

Entering 7th Grade (Bar & Bat Mitzvah On the Go): $1200

Amount to charge

$0.00

Terms and Conditions*

I, the undersigned agree, understand and authorize the amount shown above to be charged to my credit card for the items shown on the referenced order. I understand these charges will appear on my credit card statement under my name and I accept full financial responsibility for payment of this order.I agree payments are non-refundable and services / merchandise have been rendered / delivered to my satisfaction.

By entering your email you are accepting the terms above*

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

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