Child's Information First Name * Last Name * Jewish Name Gender * Male Female Date of Birth * Month January February March April May June July August September October November December Date 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 2010 2011 2012 2013 2014 2015 2016 2017 2018 Allergies? * Yes No Is there anything else we should know about your child? Does you child read and/or write in English Reading Yes No Writing Yes No Parent Information Father Mother Title * Mr. Dr. Title * Mrs. Ms. Dr. Name * Name * Home Phone * Home Phone * Cell Phone * Cell Phone * Work Phone Work Phone Email * Email * Occupation Occupation Home Address * Home Address * City * City * Province * Province * Postal Code * Postal Code * Is the father Jewish? * Select One Yes No Is the mother Jewish? * Select One Yes No Have there been any conversions or adoptions in the family (please specify)? * Emergency Contact Information Emergency Contact 1 Emergency Contact 2 Name * Name * Relationship to Child * Relationship to Child * Home Phone * Home Phone * Cell Phone * Cell Phone * Child's Medicare Number * Payment Please check those that apply: I would like information on scholarships available I would like to pay full tuition of $460 for each child in one lump sum I would like to pay full tuition of $460 for each child in instalments I would like my child to attend, but can afford to pay Terms of Registration Terms As the parent(s) or legal guardian of the above child, I/we authorize any adult acting on behalf of Chabad Kids Club to hospitalize or secure treatment for my/our child, I/we further agree to pay all charges for that care and/or treatment. I/we hereby give permission for my/our child to participate in all club activities, join in trips on and beyond Chabad properties and allow my/our child to be photographed while participating in Chabad kids club activities. I/we understand that photographs may be publicized on our website, Facebook page, and/or used for future advertising. 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 Chabad kids club and it’s associates, teachers and agents harmless therefrom. I/we consent to Chabads use of our personal information and of our child/children at its discretion in pursuit of club activities. *Enrolment in Chabad Kid's Club is not a confirmation of the student's Jewish status. Date * Signature * This page uses 128 bit SSL encryption to keep your data secure.
