We are currently accepting application forms for the 2010-2011 Bat Mitzvah Club . Please fill out ALL fields of this form. If you have any questions or concerns you'd like to discuss with us, or would like to request a printable registration form please contact us.
We look forward to a wonderful year of learning, & excitement.
Student Information
Family Name
girl 's First Name Hebrew Name Date of Birth
What school does your child attend? Synagogue affiliated with
Have there been any conversions or adoptions in the family?
Please list name and ages of siblings
Name Age Name Age formation
Father's Name Home Phone Work Phone Email adress (home) Cell Occupation Home Address Home City Home Province Home Postal Code
Marital Status Married Separated Divorced If divorced Stepfather how long Stepmother how long Mother's Name Home Phone Work Phone Email Adress (home) Cell Occupation Home Address (If different then above)Home City Home Province Home Postal Code
Emergency Contact Information
Plese list two contact to be used in case of emergencies
Name 1 Relationship to child Home Phone Cell Name 2 Relationship to child Home Phone Cell
Does your daughter have any allergies, other medical conditions or special needs we should be aware of? Yes No 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 Bat Mitzvah Club to hospitalize or secure treatment for my/our child, I/we further agree to pay all charges for that care and/or treatment. It is understood that if time and circumstances reasonably permit, Bat Mitzvah Club personnel will try, but are not required, to communicate with me/us prior to such treatment. I/we hereby give permission for my/our child to participate in all school activities, join in class and school trips on and beyond school properties and allow my/our child to be photographed while participating in Hebrew School activities. I/we also understand that all liability and costs resulting from damage to property and/or personal injury caused or attributable to my/our child/children will be my/our responsibility and I/we agree to fully indemnify and save CYN Hebrew School and it’s associates, teachers and agents harmless therefrom. I/we consent to Hallandale Bat Mitzvah club use of our personal information and of our child/children at its discretion in pursuit of school activities.
Date Initial
Tuition Fees
Fee: $330 (includes registration fee)
Location: 1295 E. Hallandale Bch Blvd
*This is non-refundable and due in full at the time of registration.
Registration must be paid in full at time of registration.
Billing info
Cash Check (Applications will be processed upon receiving of payment) Credit Card Name on card Card # Expiry
If paying by Checks or Cash please indicate below:
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Head-checks dated for each of these dates are due at registration.
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Please make all checks payable to Chabad Hebrew School and submit them together with the registration form.
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There are no refunds or credits for days missed due to illness, holidays, or family vacations.
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Charitable tax receipts will be issued for the full amount of all tuition fees paid.
Billing Information
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