BMC 2022 Registration

Child Name*

First NameLast Name

Birth Date*

Date

School*

Grade for 2022 - 2023*

YesNo

Who?

If there was a conversion - who was the Rabbi?

Shul / Synagogue affiliated with:*

Bat Mitzvah Party Date:*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Father Name*

First NameLast Name

Father Cell Number*

Please enter a valid phone number.Format: (000) 000-0000.

Mother Name*

Mother Cell Number*

Please enter a valid phone number.Format: (000) 000-0000.

I have added Hadassah Geisinsky 516-458-3694 to my contacts

Does your daughter have any allergies or medical conditions we should be award of? If yes, please describe them and indicate special precautions or care needed:*

As the parent(s) or legal guardian of the above child, I/we authorize any adult acting on behalf of Chabad 5 Towns 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 5 Towns personnel will try, but are not required, to communicate with me prior to such treatment. I hereby give permission for my child to participate in all school activities, join in class and school trips on and beyond school properties and allow my child to be photographed while participating in all activities and that these pictures may be used for marketing purposes.*

I Accept

I heard about this program from:*

BMC Registration Payment *

Chabad Member Registration

$200.00

Community Member Registration

$225.00

Enter coupon

Total

$0.00

Credit Card

First Name

Last Name

Credit Card Number

Security Code

Expiration Month

Expiration Year

Billing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Parent Information