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BMC Club Registration Form 2020 - 2021
Student Profile
First Name
Last Name
Hebrew Name
Was the natural mother born Jewish  Yes  No
Were there any conversions or adoptions in the family?  Yes  No
If yes who was the Rabbi?
Name of Shull affiliated with
Date of Bat Mitzvah Party (if known)
Parent Information
Email Address
(checked daily)
Father's Name
Father's Cell
Mother's Name
Mother's Cell

I Prefer: 

 Virtual  In Person  I'm Fleixble Either Way
What Day/s is your daughter available?

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

Emergency Information
Emergency Contact 1
Emergency Contact 2

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

I heard about this program from:

I give permission for my child’s photo to be used in newspapers / Web etc...

We will get back to you as soon as possible with the platform we will be using & the day and time. It will be based on the responses we receive on this form. 

If you have any questions please reach out to Hadassah 516-458-3694