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
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

Home Phone Number*

Area Code Phone Number
Marital Status*

Married Widowed Divorced Separated
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 Birth Converted
If converted, please specify Rabbinic Authorization
Is Maternal Grandmother?*

Jewish by Birth Converted
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:*

First Name Last Name
Relationship to Child:*
Phone Number:*

Area Code Phone Number
Secondary Emergency Contact Name:

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:*
Payment
Payment Options:*

Pay in full - Member: $2,250 2 Payments - member: $1,125 5 Payments - member: $450 Pay in full - Non Member: $2,500 2 Payments - non - member: $1,250 5 Payments - non - member: $500
Are you including the trip to NY in your payments?*

Yes No
Total

$0.00

Payment*

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

Payment

Terms of Agreement