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BMC Club Registration Form 2018 - 2019

Cost for the program for the year: $300
Chabad Members: $270

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
Was the natural mother born Jewish  Yes  No
Were there any conversions or adoptions in the family?  Yes  No
Who?
If yes who was the Rabbi?
Name of Shull affiliated with
Date of Bat Mitzvah Party (if known)
Parent Information
Address
City/Zip
Phone
Email Address
(checked daily)
Father's Name
Father's Cell
Mother's Name
Mother's Cell

All important info. & updates will be sent through a What’s App Broadcast list

In order to receive these messages,you need to have Hadassah Geisinskys contact in your phone


I have added Hadassah Geisinsky 516-458-3694 to my contacts

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:

This page uses a secure connection and your information will not be shared with anyone.
Online Payment
Payment Chabad member $270 Non member $300
Amount: $
Card Number
Last Name
City
Zip
Card Type
Exp. Date
CW#
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...