CTeen Jr Discovery Club

Full Name*

First Name Last Name

Hebrew Name*

Birth Date*

Month Day Year

School*

Grade entering*

Hebrew Reading Proficiency

NoneSomewhatWell

Previous Jewish Education

YesNo

Where?

Address*

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Is the natural mother and maternal grandmother of the child Jewish?*

YesNo

Have there been any adoptions or conversions in the family? If yes, please explain.

Father's Name*

First Name Last Name

Father's Cell*

Area Code Phone Number

E-mail

Mother's Name*

First Name Last Name

Mother's Cell*

Area Code Phone Number

E-mail

I am willing to assist in school activities, please contact me

Emergency Contact 1*

Emergency Contact 2*

Additional notable Information* Please let us know if there are any allergies or other important information we need to be aware of.

Discount Code

Registration Fees*

$50 Book Fee + $50 Security Fee

Flash Sale

I would like to make a one time payment of $892 ($792 paid-in-full discount, plus $100 registration fees).I would like to pay in eight installments of $110, and pay the $100 registration fees now.

Payment Options

I would like to make a one time payment of $936 ($836paid-in-full discount, plus $100 registration fees).I would like to pay in eight installments of $110, and pay the $100 registration fees now.

Total

$0.00

Payment

Credit Card

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

As the parent(s) or legal guardian of the above child, I/we authorize any adult acting on behalf of Chabad Hebrew School 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 Hebrew School 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 school activities, join in class and school trips on and beyond school properties and allow my child to be photographed while participating in Chabad Hebrew School activities and that these pictures may be used for marketing purposes.

*

I accept

Name Initials

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CTeen Jr - Discovery Club

Student Information

Parents Information

Emergency Information

Payment