Bat Mitzvah Club - Chabad Russian Center

We are currently accepting application forms for the 2018-2019 Bat Mitzvah Club . Please fill out ALL fields of this form. If you have any questions or concerns you'd like to discuss with us, or would like to request a printable registration form please contact us.
We look forward to a wonderful year of learning, & excitement.
Begining Oct 9th 5:30 pm - 7:00 pm, then every other Tuesday.
*Bat Mitzvah Club schedule
Girls Information
Full Name
First NameLast Name
Hebrew Name
Birth Date
MonthDayYear
School
Grade Entering
Synagogue affiliated with
Conversions or adoptions in Family
YesNo
If yes Please explain.
Mothers Information
Full Name
First NameLast Name
Phone Number
Area CodePhone Number
E-mail
Fathers Information
Full Name
First NameLast Name
Phone Number
Area CodePhone Number
E-mail
Emergency contact Information
Full Name
First NameLast Name
Phone Number
Area CodePhone Number
E-mail
Relationship to Child
Emergency contact Information 2
Full Name
First NameLast Name
Phone Number
Area CodePhone Number
E-mail
Relationship to Child
Health Information
Does your daughter have any allergies, other medical conditions or special needs we should be aware of?
YesNo
If Yes please explain
As the parent(s) or legal guardian of the above child, I/we authorize any adult acting on behalf of Bat Mitzvah Club to hospitalize or secure treatment for my/our child, I/we further agree to pay all charges for that care and/or treatment. It is understood that if time and circumstances reasonably permit, Bat Mitzvah Club personnel will try, but are not required, to communicate with me/us prior to such treatment. I/we hereby give permission for my/our child to participate in all school activities, join in class and school trips on and beyond school properties and allow my/our child to be photographed while participating in Hebrew School activities. I/we also understand that all liability and costs resulting from damage to property and/or personal injury caused or attributable to my/our child/children will be my/our responsibility and I/we agree to fully indemnify and save CYN Hebrew School and it’s associates, teachers and agents harmless therefrom. I/we consent to Hallandale Bat Mitzvah club use of our personal information and of our child/children at its discretion in pursuit of school activities.
Initial
Date
595
Fee: $595 (includes registration fee) - Does not include NY Trip and Gala
Total
$595.00

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