Childs Name *

First Name

Last Name

Mothers Name *

First Name

Last Name

Fathers Name *

First Name

Last Name

Mother Jewish by

Birth

Conversion

Adoptions or Conversions In the Family

Yes

No

Phone *

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Medical Emergencies *

I authorize the staff of Chabad of the Acres to seek appropriate medical care for my child, if necessary. As the parent(s) or legal guardian we authorize any adult acting on behalf of Chabad Jewish Club to hospitalize or secure treatment for my child, I further agree to pay all charges for that care and/or treatment.

Pictures: *

I hereby give permission for my child to be photographed. Photos may be used for promotional purposes for Chabad of the Acres.

Club dates *

Please select all claases your child will attend No club on Feb. 28

Full Session Feb. 7- March 13

February 7

February 14

February 21

March 6

March 13

Childs Name *

First Name

Last Name

Medical Emergencies *

I authorize the staff of Chabad of the Acres to seek appropriate medical care for my child, if necessary. As the parent(s) or legal guardian we authorize any adult acting on behalf of Chabad Jewish Club to hospitalize or secure treatment for my child, I further agree to pay all charges for that care and/or treatment.

Pictures *

I hereby give permission for my child to be photographed. Photos may be used for promotional purposes for Chabad of the Acres.

Club Dates *

Please select all claases your child will attend No club on Feb. 28

Full Session Feb. 7- March 13

February 7

February 14

February 21

March 6

March 13