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YOUTH & TEENS C-Girls (club) 2021-2022

C-Girls Registration

ABOUT
PHOTO GALLERY REGISTER ONLINE

We are currently accepting application forms for 2021-2022. Please fill out ALL fields of this form.
If you have any questions or concerns you'd like to discuss with us, please contact us.
*Please note that one registration form per applicant is needed.
Applicant Information
Full Name*
First NameLast Name
Hebrew Name
Age*
Birth Date*
MonthDayYear
School*
Grade Entering*

Address*

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Home Phone
Area CodePhone Number
Cell Phone
Area CodePhone Number
E-mail
Father's Information
Father's Name
First NameLast Name
Father's Religion
Father's Occupation
Father's Business Name

Father's Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Father's E-mail
Father's cell
Area CodePhone Number
Mother's Information
Mother's Name
First NameLast Name
Mother's Religion
Mother's Occupation
Mother's Business Name

Mother's Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Mother's E-mail
Mother's Cell
Area CodePhone Number
Marital Status of Parents:*
MarriedSeparatedDivorced
If divorced - how long?
Emergency Information
In case of emergency, when neither parent can be reached, please list two contacts who will take responsibility for your child:
Emergency Contact 1*
First NameLast Name
Relation to Child*
Phone Number*
Area CodePhone Number
Business Phone
Area CodePhone Number
Emergency Contact 2*
First NameLast Name
Relation to Child*
Phone Number*
Area CodePhone Number
Business Phone
Area CodePhone Number
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.
If parents cannot be reached and emergency medical advice is needed, permission is given to the BMC staff to phone my child’s doctor:
Doctor's Name*
First NameLast Name
Doctor's Phone*
Area CodePhone Number

Doctor's Address*

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Doctor's Hospital Affiliation*
Permission for Emergency Medical Treatment:*
In case of emergency requiring immediate emergency care, I authorize the paramedics to take my child to the nearest hospital if necessary.
Payment Plan
Which program would you like to enroll your daughter in?
Once a week - $1200 All InclusiveEarly bird special until Aug 1: $1,000 save $200Early bird special after 8/1-8/15: $1,100 Save $100
Commitment*
I understand that by submitting this form I am committing to pay the above outlined tuition fees.
Name*
First NameLast Name
Initials*
Date*
MonthDayYear
Secure Online Payment

Payment*

Credit Card Cash or Check

Postal / Zip Code

Country

Amount to charge my card today
$1200$1100$1000
Total
$0.00
Should be Empty:

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