Bat Mitzvah Club Registration

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Please fill out this form as an initial registration for Bat Mitzvah Club.

Confirmation of acceptance will be acknowledged only after this registration form is reviewed and an acceptance letter is received.

Member Information

   
     Male Female

Does you child read basic Hebrew? None  Somewhat Well

Does your child speak/understand Hebrew? None  Somewhat Well

Does your child have previous Jewish Education Yes No
If yes, please describe:

What school does your child attend?  Grade entering:  
Is the natural mother of the child Jewish? Yes No
Were there any conversions or adoptions in your family? Yes No
If yes, please describe:

Any considerations, such as learning disorder or difficulty, the school should be aware of? (Confidential):

Parent Information
   
   
 
  

   
  

  

Emergency Contact Information
Please list two contacts to be used in case of emergencies (other than your home and business numbers).
 
   

 
   

 
 

  
Please send a copy of your insurance card for our files.

Up to date with vaccinations? Yes No           Date of last tetanus shot:
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.

As the parent(s) or legal guardian of the above child, I/we authorize any adult acting on behalf of Chabad 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 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 activities, join in club trips on and beyond Chabad properties and allow my child to be photographed while participating in Chabad activities.
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Initial here:  

Tuition Agreement

The following is a tuition agreement for Bat Mitzvah Club. The agreement explains the tuition fees, payments plans and refund policies. Please read it through carefully. If paying by check or cash, full payment must be submitted before any child will be permitted to attend.

The tuition for Bat Mitzvah Club is $465.00 per year per child. $235 if your child is enrolled in Chabad Hebrew School (this includes a registration & book fee).


You may choose from the following payment methods:
PLAN A: You may pay the entire amount in full with a check, cash or credit card.

PLAN B: You may pay the annual tuition on a monthly basis by submitting 10 checks of $46.50 each, or $23.50 each if your child is enrolled in Chabad Hebrew School, dated September through June. All checks must be submitted before the first day.
PLAN C: You may use your credit card to pay the tuition on a monthly basis.  Your credit card will be billed $46.50, or $23.50 if your child is enrolled in Chabad Hebrew School, monthly September through June.  To do so please include your credit card number and expiration date at the bottom of this page.

Refunds for children withdrawing before the end of the school year will be pro-rated up to February 1 provided that Chabad is given 30 days written notice and does not include a $50 registration and book fee. Tuition refunds will not be granted to children withdrawing after February 1. There are no refunds or credits for days missed due to illness, holidays, or family vacations.
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Your FULL name here:  

Payment Options:
VISA MasterCard American Express Check in mail

Check or Card No.
Check Date or Card Expiration: mm/yyyy /

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