Registration Bat Mitzvah

Cteen Jr
Bat Mitzvah & Teen Club.

Chabad Hebrew School
Thursday Nights @ Chabad
6:00 - 8:00 PM

Child 1

Full Name*

First Name Last Name

Hebew Name*

Birth Date*

Month Day Year

Age*

School Entering*

Grade*

Bat Mitzvah &Teen Club*

$650

Parents Information

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

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*

Month Day Year

Payment Options

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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