Mother Name
*
First Name
Last Name
Mother's Hebrew Name
First Name
Last Name
Mother Phone Number
*
(###)
###
####
Mother Email
*
Mother's Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Mother is:
*
Jewish by Birth
Jewish by Choice
Not Jewish
If any conversions or adoptions, please explain here:
Father Name
*
First Name
Last Name
Father's Hebrew Name
First Name
Last Name
Father Phone Number
*
(###)
###
####
Father Email
*
Father's Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Father is:
*
Jewish by Birth
Jewish by Choice
Not Jewish
If any conversions or adoptions, please explain here:
Marital Status of Parents
Married
Divorced
Widowed
Does someone other than the parent(s) care for your child? Please explain here:
Child's Name
*
First Name
Last Name
Child's Hebrew Name
*
Child's Birthday
*
MM
DD
YYYY
Was child born after sunset?
*
YES
NO
Child's Current School
*
Child's Current / Entering Grade in School
*
Does your child have any allergies, medical conditions or special needs we should be aware of? If yes, please explain here.
Please tell us about your child, strengths, weaknesses, disposition and anything else that will help us best serve your child.
Name
*
First Name
Last Name
Relationship to Child
*
Phone Number
*
(###)
###
####
RELEASE OF INFORMATION AND PHOTOGRAPHS
*
Parents allow for child(ren)'s picture to be used for internal PR mailing and website where name is not given. Parents allow for child(ren)'s photograph/name released to newspapers where last name will not be given. If not, please contact us.
MEDICAL RELEASE
*
As the parent(s) or legal guardian of the above child/ren, I/we authorize any adult acting on behalf of Chabad of Miami Bat Mitzvah Club 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 Miami Bat Mitzvah Club personnel will try, but are not required, to communicate with me prior to such treatment.
TRIPS AND OUTINGS RELEASE
*
I hereby give permission for my child to attend and participate in all trips and outings organized as part of the program by Chabad of Miami Bat Mitzvah Club.
PRIVACY RELEASE
*
I hereby give permission for my child’s photographs/videos to be used in newsletters, local newspapers, Chabad of Miami Bat Mitzvah Club website or for promotion of our program.
DISPOSITION
*
Parent acknowledges that Chabad of Miami Bat Mitzvah Club serves children who are able to function successfully in a group setting. If, in the judgment of the program's Director, the child is not able to function in a group setting, the parent may be asked to withdraw the child. In the event that the parent is request to withdraw the child, the Director will work with the parent to identify possible alternative programs suitable for the child.
Enrollment is $360/child. Full payment, or the first payment in the case of a payment plan, is due at the beginning of the program, September 1, 2020. Enrollment is considered to be for the entire program. There will be no refunds even if the child is absent due to illness, holidays, vacations and snow days, or should the parents decide to withdraw the child from the program. Checks or any major credit cards are accepted (you will be taken to a page for payment upon completing this form).
*
Mother's Initials
*
Father's Initials
*
