Bat Mitzvah Club Enrolment - JewishMelbourne.com.au

BAT MITZVAH GIRL INFORMATION

Full Name*

First Name Last Name

NIckname name they like to be called

Jewish Name (if known)

Birth Date*

Day Month Year

School

Grade while attending the program*

Program Year

Food or Drug Allergies?*

please write NA if none

Any Medical Conditions (asthma or others)?*

please write N/A if none

Epipen Required

Special Comments

FAMILY INFORMATION

Address

Street Address
Street Address Line 2
City	State
Post Code	Country

Does the child live with both parents?*

Yes No

Primary E-mail Address

all our correspondence will be via email.

Parent 1*

First Name Last Name

Contact Number*

Phone Number

Parent 2

First Name Last Name

Contact Number

Phone Number

E-mail Parent 2

Home Phone Number

Area Code Phone Number

Rabbi at parent's marriage (if divorced or currently married)*

The natural mother of the child is Jewish*

By birth By choice No

Are there any conversions in the family?*Parents *Grandparents, *Great-Grandparents*

Yes No

If yes, please specifiy whom and through which organisation

EMERGENCY INFORMATION

Emergency Contact other than Parents*

First Name Last Name

Emergency Contact Number*

Area Code Phone Number

Relationship to Child

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 I hereby authorise LChaim Chabad or Moorabbin HC staff and/or volunteers to photograph my child and use the photographs at their discretion.

I agree to the above declaration*

Yes

Name of Person authorising*

Direct Debit

$50 Deposit/ $450 Total Tuition

L'Chaim Chabad-Kingston & MHC BatMitzva Club will debit $150 (minus initial Term 1 deposit) from the above credit card at the end of Term 1, 2 & 3. For any other arrangements, please contact us prior to the start of the year.

Deposit*

$50

Payment*

Credit Card

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

Please note: Registration is only confirmed after direct communication from the director.

Leah can be reached on 0425 844 050 or [email protected]

Looking forward to a fantastic year of growth, excitement and experiences.