Registration

CLICK HERE for program options:

For more information e-mail [email protected]

Father's Name*

PrefixFirst NameLast Name

Father's E-mail*

Father's Cell Phone*

Area CodePhone Number

Father's Work Phone

Area CodePhone Number

Mother's Name*

PrefixFirst NameLast Name

Mother's E-mail*

Mother's Cell Phone*

Area CodePhone Number

Mother's Work Phone

Area CodePhone Number

Parent's Marital Status*

Student's Full Name*

First NameLast Name

Hebrew Name*

Age*

Grade*

Birth Date*

MonthDayYear

Gender*

FemaleMale

Home Address*

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

Home Phone Number*

Area CodePhone Number

Allergy or Health Information

Does your child's allergies require the use of an Epi Pen?*

YesNo

Does your child have any learning or behavioral challenges?*

YesNo

If yes, please specify.

Has your child attended Hebrew School in the past?*

YesNo

Does your child read basic Hebrew?*

YesNo

If Yes, How well?

Would you be interested in a Bar/Bat Mitzvah Program outside of regular programming?*

YesNo

Which school does your child attend?*

Program Options:*

In person Sunday 10:30 am- 12:00 pm at Uptown Chabad Shul 92 Clanton ParkVirtual Wednesday 4:30 pm- 6:00 pmPods- minimum 4 children (5% discount for host)Pods- less than 4 childrenAleph Champ experience

*All options include 15 minute weekly one on one Aleph Champ session.

Pods Info: List names of children in group or request to be paired up. Include preferred day of the week and time and hosts name.

Total

$0.00

Please note that photos taken during school may be used for promotional or publicity purposes.

Is the biological mother of the child Jewish?*

YesNo

Were there any Jewish Conversions in your family?*

YesNo

If yes, please provide details:

Were there any adoptions in your family?*

YesNo

Does your family have membership with a Synagogue?*

YesNo

If yes, please specify:

# 1 Full Name

First NameLast Name

Phone Number

Area CodePhone Number

Address

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

#2 Full Name

First NameLast Name

Phone Number

Area CodePhone Number

Address

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

Relationship to Child

Child will not be released to any individual not in this section unless otherwise indicated in writing by parents/guardian.

Book fees are included.

A tax deductible donation receipt will be issued for the full amount.

Please note: There are no refunds or make-up classes for illness or family vacations.

Credit cards will be processed at the beginning of the session.

Payment:*

Credit Card

Credit Card Type
Credit Card Number
Name on Card
Expiration Month	Expiration Year

Billing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Comments

Parent Information

Student Information

Authorizations for Pick-Up

Payment Information