Register - Bais Chabad Torah Center

STUDENT INFORMATION
We are currently accepting application forms for: Mommy 'n Me Summer 2019. Please fill out ALL fields of this form. If you have any questions or concerns or would like to request a scholarship, please contact us at 248-865-1541 or zeesy@baischabad.com.
Full Name
First NameLast Name
Birth Date
MonthDayYear
Hebrew Name
Jewish Education Current/Previous
YesNo
If yes, where?
Siblings names and ages
Is there any information concerning your child that is important for the directors of Bais Chabad Youth Zone to know?
Does your child have asthma, food allergies or any other medical condition?
YesNo
Do you give permission to use photographs of your child in print materials, on our website and emails?
YesNo
PARENT INFORMATION
Father's Name
First NameLast Name
Father's E-mail
Mother's Name
First NameLast Name
Mother's E-mail

Address

Payment

Credit Card

Billing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

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