BAM Online Registration

Full Name*

First Name Last Name

Hebrew Name

First Name Last Name

Age*

Birth Date*

Month Day Year

I would like to receive news and updates by email

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Phone Number

Area Code Phone Number

Gender*

MaleFemale

Does your Child have a previous Jewish Education

YesNO

If yes please Explain

What School does your child attend?

Grade?

Is the mother of the Child Jewish

YesNO

Were there any conversions in the family?

YesNO

If yes please describe

Any considerations, such as learning disorder or difficulty, the shcool should be aware of?

Track Selection:*

In person

Fathers Name

First Name Last Name

E-mail

Phone Number

Area Code Phone Number

Cell Number

Area Code Phone Number

Occupation

Mothers Name

First Name Last Name

E-mail

Phone Number

Area Code Phone Number

Cell Number

Area Code Phone Number

Occupation

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Emergency Contact

Relationship to child

Phone Number

Area Code Phone Number

Mobile Number

Area Code Phone Number

Doctor

Address

Phone Number

Area Code Phone Number

Allergies or other Medical Conditions

As the Parent of legal guardian of above mentioned child. I/we authorize any adult acting on behalf of Chabad Teen Program 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 Teen Program personnel will try, but are not required, to communicate with me prior to such treatment.

Parents Name

Date

The following is a tuition agreement for the Chabad Teen Program. The agreement explains tuition fees, payment plans and refund policies. Please it through carefully.

Scholarships are also available, please see Scholarship form. No child will ever be turned away due to lack of funds.

Please Choose from the Following payment options.

Please choose one

Plan A: You may pay the full amount with a check, cash or credit card.Plan B: You pay the annual tuition on a monthly basis by submitting 5 Checks of $36.00 each. All checks should be submitted before the 1st day of shcool.PLac C: You may use your credit card to pay tuition on a monthly basis. . Your credit card will be billed $36.00 monthly Jan - May. To do so please Include your credit card info below.

Payment

Credit Card Other

Postal / Zip Code

Country

Monthly for 5 months

$36

One time Charge

$180

Other amount please specify

Student Information

Parent Information

Emergency Information

Tuition Agreement