Chai Five Registration Form 2018/2019

Filling out form does not mean acceptance, applicants are accepted based on first come first served basis, based on limited space available.

Student Profile
First Name
Last Name
Hebrew Name
DOB
School
Grade Entering
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Parent Information
Address
City
State
Zip
Phone
Email Address
(checked dialy)
Father's Name
Father's Cell
Mother's Name
Mother's Cell
Name of Shul affiliated with

Mother Converted  

 Mother Not Jewish
Emergency Information
Emergency Contact 1
Phone
Emergency Contact 2
Phone
Doctor's Name
Doctor's Phone Number
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 5 Towns 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 5 Towns 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 all activities and that these pictures may be used for marketing purposes.

I Accept

Should you wish to pay online

Name:
Initials:

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Online Payment
Payment Chabad member $162 Non member $180
Amount: $
Card Number
Last Name
Card Type
Exp. Date
CVV Code
I understand that my money is not refundable.
I heard about this program from:
I give permission for my child’s photo to be used in newspapers / Web etc...