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First & Last Name   Hebrew Name
Age   D.O.B.
School   Grade Entering
Address   Apt.
City, State, Zip
City State Zip
  Home Phone
Child's Cell Phone   Child's Email
Name of Sibling: 1.   Age:
2.   Age:

Father's Name   Religion
Occupation   Business Name
Address   City, State, Zip
City State Zip
Email   Cell
Father Facebook      
Mother's Name   Religion
Occupation   Business Name
Address   City, State, Zip
City State Zip
Email   Cell

Mother Facebook      
CONFIDENTIAL: Is the natural mother of the child Jewish? Yes no
Were there any conversions or adoptions in the family? no yes
If Yes, please describe:
Marital Status of Parents: Married Separated Divorced - How long?
Please share any other information you feel is important for us to be aware of. This can include exceptional behavior, concerns, particular activities, family relationships etc.


Please list below two emergency contacts
Emergency Contact 1   Relation to Child
Phone   Business Phone
Emergency Contact 2   Relation to Child
Phone   Business Phone

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.

Doctor's Name   Doctor's Phone
Doctor's Address   City, State, Zip
City State Zip

Permission for Emergency Medical Treatment:

As the parent(s) or legal guardian of I/we authorize any adult acting on behalf of Chabad Neshama 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 Neshama personnel will try, but are not required, to communicate with me prior to such treatment.


For questions, comments or discounted rates, contact us at

Payments can be made by cash or check mailed to 321 Seabreeze Ave.

I understand that by submitting this form I am committing to pay the above outlined tuition fees.

Name: Initials: Date:


PROGRAM DATES - February 19 - 23, 2018

Full week - 5 days $350
Per day - $75

Please select which days your child will be attending:
Monday Tuesday Wednesday Thursday  Friday


 Payment Method: Cash or check     Credit card

 Billing Name iiiiiiiiiiiiiiiiiiiiiBilling Address - Street, City, State & Zip

Card Numberiiiiiiiiiiiiiiiiiii CVV Codeiii      iiiiiiiiiiiiiiiExpirationiiiii    iiiiiiiiiiiiiiTotal $ to Charge Card 
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