Bat Mitzvah Club Registration - ChabadGleneira.com

Address* Child's Primary Address

Is the natural mother of the child Jewish*

YesNo
Are there any conversions in the family*

Yes - Please answer next questionNo
If yes, please provide conversion details
Synagogue affiliation (if any)
Emergency Information
Emergency Contact*

First Name Last Name
Relationship to Child*
Emergency Phone*
Emergency Mobile
Local GP Name
Local GP Number
Declaration of Parent or 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*

Checked
Declaration Name*

First Name Last Name
Deposit*

$50

Payment*

Credit Card

Direct Debit

Chabad Glen Eira Gems Bat Mitzvah Club will debit $170 (minus term 1 deposit) from the above credit card at the start of each term. If this is an issue please contact us prior to the start of the year to make other arrangements.
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Registration form