Pesach 4D experience Holiday ProgramCHILD 1 INFORMATIONChild 1 Full Name*First NameLast NameNIcknamename they like to be calledBirth Date*12345678910111213141516171819202122232425262728293031Day1 - January2 - February3 - March4 - April5 - May6 - June7 - July8 - August9 - September10 - October11 - November12 - DecemberMonth2019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920YearSchoolGrade 2019*PrepYear 1Year 2Year 3Year 4Year 5Year 6What day is my child attending? Select 1*Sunday April 14Tuesday april 16MEDICAL INFO & SPECIAL NEEDSGP Name*GP Number*Any Allergies?*please write NA if noneMedical Conditions (asthma or others)?*please write N/A if noneChild Special Needs/Difficulty (Disability)Special CommentsCHILD 2 INFORMATIONChild 2 Full NameFirst NameLast NameChild 2 Nicknamename they like to be calledBirth Date1 - January2 - February3 - March4 - April5 - May6 - June7 - July8 - August9 - September10 - October11 - November12 - DecemberMonth12345678910111213141516171819202122232425262728293031Day2019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920YearSchoolGrade 2019PrepYear 1Year 2Year 3Year 4Year 5Year 6What day is my child attendingTuesday April 16Child 2 MEDICAL INFO & SPECIAL NEEDSGP NameGP NumberAny Allergies?please write NA if noneMedical Conditions (asthma or others)?please write N/A if noneChild Special Needs/Difficulty (Disability)Special CommentsFAMILY INFORMATIONAddressStreet AddressStreet Address Line 2CityStatePost CodePlease SelectUnited StatesAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanThe BahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChilePeople's Republic of ChinaRepublic of ChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCook IslandsCosta RicaCote d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonThe GambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNagorno-KarabakhNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandTurkish Republic of Northern CyprusNorthern MarianaNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint BarthelemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSomalilandSouth AfricaSouth OssetiaSpainSri LankaSudanSurinameSvalbardSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTransnistria PridnestrovieTrinidad and TobagoTristan da CunhaTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamBritish Virgin IslandsUS Virgin IslandsWallis and FutunaWestern SaharaYemenZambiaZimbabweOtherCountryFamily E-mailParent 1*First NameLast NameContact Number* Phone NumberParent 2First NameLast NameContact Number Phone NumberHome Phone NumberArea CodePhone NumberEmergency Contact other than Parents*First NameLast NameEmergency Contact Number*Area CodePhone NumberAuthorised Person1 to collect the childFirst NameLast NameAuthorised Person2 to collect the childFirst NameLast NameIs the natural mother of the child Jewish*YesNoAre there any conversions in the family?*YesNoIf yes, please specifiy whom and through which organisationAUTHORISATIONSMedical Authorisation*I hereby authorise a L'Chaim Chabad or Moorabbin HC staff and/or volunteer to obtain any medical care necessary for my child, including from a medical practitioner, hospital or ambulance service. I understand that transportation to receive medical care may include an ambulance and I agree to pay for any costs involved with seeking medical care for my child. I understand that in the case of an emergency of significant illness or injury attempts will be made to contact myself or an authorised nominee, as soon as practical*I hereby authorise L"Chaim Chabad or Moorabbin HC staff and/or volunteers to photograph my child and use the photographs for L'Chaim Chabad or Moorabbin HC for the following purposes:yes, Educational purposesyes, promotional materialyes, social mediaI hereby authorise L'Chaim Chabad or Moorabbin HC staff and/or volunteers to take my child on walks outside the facility*yesnoPAYMENT INFORMATION Cost is $10/per child due to a generous donor. PaymentCredit Card Direct Debit Credit CardVisaMasterCardCredit Card TypeCredit Card NumberName on Card1 - January2 - February3 - March4 - April5 - May6 - June7 - July8 - August9 - September10 - October11 - November12 - DecemberExpiration Month2019202020212022202320242025202620272028Expiration YearPlease contact office@jewishmelbourne.com.au to arrange. Enrolment is not confirmed until payment is arranged.SubmitShould be Empty: This page uses TLS encryption to keep your data secure.
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