Young Leadership Club Registration 2024

Young Leadership Club

Building confident leaders!
Child Name*

First NameLast Name
Hebrew Name
If known
Child's School as of September 2024*
Child's Grade as of September 2024*
Birth Date*

MonthDayYear
Date
My child was born in the*

MorningEvening
Was the Birth Mother Born Jewish*

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

YesNo
Please specify*
If there was a conversion - who was the Rabbi?*
Does your child have any allergies? What should be done in the case of an allergic reaction?
Parent Information
Mother Name*

First NameLast Name
Mother Cell Number*
Please enter a valid phone number.
Father Name*

First NameLast Name
Father Cell Number*
Please enter a valid phone number.
Parent Email *
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please read and check the box to accept*

My child, the young leader, acknowledges the program's need for maturity and responsibility. She willingly chooses to join, prepared to actively and respectfully participate in lessons and discussions.
Payment Information: $180 for the year

Please note: No one will be turned away due to lack of funds. Please submit this form and contact Hadassah for financial assistance or a payment plan: 516-458-3694
Payment Options

I will be sending in cash / checkCredit Card

Leadership Course Payment*

Leadership Club 2024 - 2025

$180.00

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

Young Leadership Club