HC Registration

Child Info

Full Name

First Name Last Name
Jewish Name

First Name
Gender

Male Female
DOB

Month Day Year
Grade the child is entering in September 2022:*
I would like my child picked up from Norman S Edelkop SIB K-8*

Yes No - I will bring my child to WINNERS GYM
Teacher Name:*
Room Number*
Is the natural mother of the child Jewish?*

Yes No
Are there any Conversions in the family?*

Yes No
If yes please explain

Family Information

Address

Address - If different than father

Emergency contact - Someone other than parents, in case we can not reach parent

Allergy Information

Please provide any allergy or other medical information that we should know about:

Allergies
I hereby give permission for the Chabad Russian Center Hebrew Club to seek medical attention for my child in the event of an accident / emergency and further give permission for my child to be transported to and from excursions.
Signed
Payment Options*
I would like to make a donation to help cover the cost of this program, and to sponsor any chld who may not be able to affford the program

$180 $360 $500 $770 $900 $1200
Total

$0.00

Yes, I'd like to donate the cost of processing this transaction by adding 2.9%

Payment

Credit Card Paypal Other

Postal / Zip Code

Country

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Hebrew Club Enrollment Form