Registration - Chabad of Fairfield

Bat Mitzvah Club Registration
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:
Applicant's Information:
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.
Payment:
Payment Options:*
Pay Tuition in Full Now: $200Pay $100 now and $100 on February 1, 2022Please send me info on financial assistance.
Total
$0.00
Yes, I'd like to donate the cost of processing this transaction by adding 3%

Payment

Credit Card Check

Postal / Zip Code

Country

This page uses TLS encryption to keep your data secure.

Bat Mitzvah Club