Young Leadership Club Registration 2025

Child Name*

First NameLast Name

Hebrew Name

If known

Child's School as of September 2025*

Child's Grade as of September 2025*

Birth Date*

Date

MorningEvening

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?

Mother Name*

First NameLast Name

Mother Cell Number*

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

Father Name*

First NameLast Name

Father Cell Number*

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

Parent Email *

example@example.com

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

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

I will be sending in cash / checkCredit Card

Leadership Course Payment*

Leadership Club 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

Parent Information