The Bar Mitzvah Enichment course 2018 To join and find out more about the Bar Mitzvah Enrichment course please contact Moshe on 0430 087 879 or email [email protected] or complete the form below: BAR MITZVAH BOY'S INFORMATION Surname First Name Date of Birth (dd/mm/yyyy) Grade School MEDICAL INFORMATION Any medical conditions Drug/Food allergies Is tetanus booster up to date Is an EPIPEN Required No YES - EPIPEN If your child has an Epipen, please ensure it is brought to every lesson. MOTHERS INFORMATION Surname First Name Email Home Phone Mobile FATHERS INFORMATION Surname First Name Email Home Phone Mobile CHILDS PRIMARY ADDRESS Street Number & Street Name Suburb & Postcode Marital Status Is the natural mother of the child Jewish Yes No Synagogue affiliation (if any) EMERGENCY INFORMATION Full Name Relationship to child Phone Mobile Local GP Name Local GP Phone DECLARATION OF PARENT / GUARDIAN I hereby authorise Chabad House Glen Eira leaders and staff to obtain any medical care necessary for my child. I understand that in the case of emergency of any significant illness or injury, attempt will be made to contact myself when practical. I agree to pay for any cost that may occur as a result of the injury/illness. I acknowledge my child may be participate in activities within and outside the Chabad grounds. I authorise my child to participate in these activities. I hereby authorise Chabad House Glen Eira to photograph my child and to use the photographs at their discretion. I agree to the above declaration. Full Name Date PAYMENT Secure online payment The cost of the Bar Mitzvah enrichment program is $180. There are 18 classes. Card Type Visa Master Card Name on card Card number Exp Amount One installment of $180 Two installments of $90 each term This page uses 128 bit SSL encryption to keep your data secure.
The Bar Mitzvah Enichment course 2018
