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Registration

Child Information
Child's Name*
First Name Last Name
Child's Hebrew Name*
Birth Date*

Month Day Year
My child was born in the*

DayEvening (after Sunset)
Child's school as of September 2025*
Child's grade as of September 2025*
Please specify any medical or behavioral concerns that we should be aware of: By sharing this information, you help us help your child.
Does your child have any allergies? What should be done in the case of an allergic reaction?
Parent Information
Mother Name*
First Name Last Name
Mother Cell Number*
Mother Email*
Father Name*
First Name Last Name
Father Cell Number*
Father Email*
Marital Status*

MarriedSeperatedDivorced
How did you hear about Chabad of Sheepshead Bay Bat Mitzva Club?*
Was the Mother born Jewish?*

YesNo
Please specify*
Were there any conversions or adoptions in the family?*

YesNo
Please specify*
Who was the Rabbi?*

Address*

Emergency Information
Emergency Contact*
First Name Last Name
Cell Phone Number*
Relationship*
Disclaimer
As the parent(s) or legal guardian of the above child, I/we authorize any adult acting on behalf of Chabad of Sheepshead Bay to hospitalize or secure treatment for my child. I further agree to pay all charges for that care and/or treatment. It is understood that if time and circumstances reasonably permit, Chabad personnel will try, but are not required, to communicate with me prior to such treatment. I hereby give permission for my child to attend all field trips and outings sponsored by Chabad of Sheepshead Bay.
*

I agree
I hereby give permission for my child’s photographs/videos to be used in newsletters, local newspapers, Chabad Five Towns website or for promotion of our program.
*

I agree
Payment
Tuition: $250
Includes all 8 classes

No one will be turned away due to lack of funds - once you submit your form please contact Chayale- [email protected] to discuss financial assistance or a payment plan. We are happy to help.
I would like to sign my daughter up for the program*

Yes
Total

$0.00
I am unable to pay at the moment. I will reach out to Chayale regarding financial assistance or a payment plan

Payment*

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Credit Card Number	Security Code
Name on Card
Expiration Month	Expiration Year

Billing Address

Street Address

City

State / Province

Postal / Zip Code

Country

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Child Information