Registration - ChabadFL.org

Child Information
Child's Name*
First Name Last Name
Hebrew Name*
Birth Date*

Month Day Year
School*
Cell Number

Area Code Phone Number
E-mail
PLEASE ADD YOUR DAUGHTER’S FRIEND (S) REQUEST* (If there isn’t a friend request, please write N/A)
Parents Information
Father's Name*
First Name Last Name
Mother's Name*
First Name Last Name

Address*

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Father’s address is different than mother’s address

Father's Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Marital Status*

MarriedWidowedDivorcedSeparated
Father Cell*

Area Code Phone Number
Father Work #*

Area Code Phone Number
Mother Cell*

Area Code Phone Number
Mother Work #*

Area Code Phone Number
Father's E-mail*
Mother's E-mail*
Is mother?*

Jewish by BirthConverted
If converted, please specify Rabbinic Authorization
Is Maternal Grandmother?*

Jewish by BirthConverted
If converted, please specify Rabbinic Authorization
For conversion, please provide us with Certificate of Conversion and Marriage Ketubah. Please note: All Conversions must be accepted by the Orthodox Rabbinical Court, before child can be admitted to Aventura Chabad’s Bat Mitzvah Club
Siblings:
Sibling 1:
Sibling 2:
Sibling 3:
Emergency Contact
Primary Emergency Contact Name:* (Someone other than parent)
First Name Last Name
Relationship to Child:*
Phone Number:*

Area Code Phone Number
Secondary Emergency Contact Name: (Someone other than parent)
First Name Last Name
Relationship to Child:
Phone Number:

Area Code Phone Number
Medical Information
Hospital/Clinic Preference:*
Physician’s Name:*
First Name Last Name
Physician’s Phone Number:*

Area Code Phone Number
Insurance Company:
Policy Number:
Allergies/Special Health Considerations:
Authorization:*

I authorize all medical and surgical treatment, X-ray, laboratory, anesthesia, and other medical and/or hospital procedures as may be performed or prescribed by the attending physician and/or paramedics for my child and waive my right to informed consent of treatment. This waiver applies only in the event that neither parent/guardian can be reached in the case of an emergency.I give permission for my child to go on field trips. I release Aventura Chabad and individuals from liability in case of accident during activities related to Aventura Chabad, as long as normal safety procedures have been taken.By entering your first and last name below, you electronically acknowledge having read and understood this Agreement and agree to the terms and conditions herein.Your first and last name below represents your agreement to all the terms and conditions written above and will serve as your consent to all the terms and conditions written above.
Signature:*
First Name Last Name
Date:*
Cost of Program
***ALL CREDIT CARD PAYMENTS INCUR A 3.5% PROCESSING FEE.
Members: $2,500
Non-Members: $2,750
NY Trip: $950

1^st payment due on date of registration: (if payment in full is made, this fee does not get paid separately)
Members: $650
Non-Members: $750
Payment Plans
Payment Options:

Pay in full - Member: $2,2502 Payments - member: $1,1255 Payments - member: $450Pay in full - Non Member: $2,5002 Payments - non - member: $1,2505 Payments - non - member: $500
Are you including the trip to NY in your payments?

YesNo
We are:*

MembersNon-Members
Members*

Payment in full, including NY Trip ($3,450)Payment in full, without NY Trip ($2, 500)Deposit + 2 Payments, including NY Trip ($650 today, Sept & Nov: $1,400 ea.)Deposit + 2 Payments, without NY Trip ($650 today, Sept & Nov: $925 ea.)Deposit + 5 Payments, including NY Trip ($650 today, Sept-Jan: $560 ea.)Deposit + 5 Payments, without NY Trip ($650 today, Sept-Jan: $370 ea.)
Non-Members*

Payment in full, including NY Trip ($3,700)Payment in full, without NY Trip ($2,750)Deposit + 2 Payments, including NY Trip ($750 today, Sept & Nov: $1,475 ea.)Deposit + 2 Payments, without NY Trip ($750 today, Sept & Nov: $1,000 ea.)Deposit + 5 Payments, including NY Trip ($750 today, Sept-Jan: $590 ea.)Deposit + 5 Payments, without NY Trip ($750 today, Sept-Jan: $400 ea.)
Total

$0.00

Payment*

⚠ You have not yet connected a credit card processor.

Credit Card Check

Postal / Zip Code

Country

CVV
Terms of Agreement
(PLEASE READ CAREFULLY-NO EXCEPTIONS)
I understand:*

1. Payment in full is due with application, including all head checks or credit cards.2. Payment is Non-Refundable, for any reason, even if your child does not attend the program.3. Withdrawal of enrollment privileges, for any reason, does not relieve the Undersigned of the responsibility for the payment of the entire financial obligations for the program you enrolled your child in.4. By entering your first and last name below, you electronically acknowledge having read and understood this Agreement and agree to the terms and conditions herein.5. Your first and last name below represents your agreement to all the terms and conditions written above and will serve as your consent to all of the terms and conditions written above.
Signature:*
First Name Last Name
Date:*
Should be Empty:

Child Information

Parents Information

Siblings:

Emergency Contact

Medical Information

Cost of Program

Payment Plans

Terms of Agreement