Bat Mitzvah club 2023-2024

Student Information:

Full Name*

First Name Last Name

Hebrew Name

Date of Birth*

Month Day Year

School*

Grade Entering*

Previous Jewish Education

Where?

Parent Information:

Father's Name*

First Name Last Name

Father's Phone Number*

Area Code Phone Number

Father's E-mail*

Is father Jewish?

Mother's Name*

First Name Last Name

Mother's Phone Number*

Area Code Phone Number

Mother's E-mail*

Is mother Jewish?

Emergency Information:

Emergency Contact 1*

Phone Number*

Area Code Phone Number

Emergency Contact 2*

Phone Number*

Area Code Phone Number

Doctor*

Phone Number*

Area Code Phone Number

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.

Payment Information:

Bat Mitzvah club Registration:* Includes Textbooks and Supplies

Full Payment $10008 Monthly Installments $125/month (Oct-May)

Please consider an added donation to our scholarship fund

Total

$0.00

Yes, I'd like to donate the cost of processing this transaction by adding 3%

Payment*

Credit Card

We accept Visa, MasterCard, American Express, Discover
Credit Card Number	Security Code
Name on Card
Expiration Month	Expiration Year

Billing Address

Street Address

City

State / Province

Postal / Zip Code

Country

Authorization:

Transport / Emergency Care as listed above Authorization:

I hereby give permission for my child to be transported to and from field trips, and to participate in them in all RSF Hebrew School activities. I understand that during the course of RSF Hebrew School my child can be hurt. I accept the risk of possible injury and authorize any member of the Chabad RSF Hebrew School staff to render any necessary first aid. Furthermore, in an emergency case, I hereby authorize Devorah Raskin, Rabbi Levi Raskin or another staff member to have my child taken care of by a physcian or other medical person in any way the situation calls for.

Transport / Emergency Care as listed above Authorization*

I give permissionI don't give permission

Initials Here:*