Registration - Chabad of Fairfield

Bat Mitzvah Club Registration
Girl's Name:*
First NameLast Name
Hebrew Name:*
Birth Date:*
MonthDayYear
School Currently Attending:*
Previous Jewish Education:*
Current Grade:*
CONFIDENTIAL: Does your child have any allergies or other medical condition we should be aware of? If yes, please describe them and indicate special precautions or care needed.
Parent's Information:
Father's Name:*
First NameLast Name
Father's Cell:
Area CodePhone Number
E-mail:
Mother's Name:*
First NameLast Name
Mother's Cell:
Area CodePhone Number
E-mail:
Payment:
Payment Options:*
Pay Tuition in Full Now: $250Pay $125 now and $125 on February 1, 2019Please send me info on financial assistance.
Total
$0.00

Payment

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Postal / Zip Code

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Bat Mitzvah Club