Bat Mitzvah Academy

Parents Information
Parent Name
First Name Last Name
Mother's Hebrew Name (If known)
E-mail*
Cell
Is the natural mother of the child Jewish?

YesNo
If applicable, please descibe any conversions or adoptions in your family
Student Information
Full Name*
Hebrew Name
Birth Date

Month Day Year
Additional notable Information Please let us know if there are any allergies or other important information we need to be aware of.
Accident, Privacy & Field Trip Declaration
Accident: As the parent(s) or legal guardian of [child(ren) listed], I/we authorize any adult acting on behalf of Chabad of Fremont 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 personnel will try, but are not required to communicate with me prior to such treatment.

Trips & Outings: I hereby give permission for my child to attend and participate in all trips and outings organized as part of the program.

Privacy: I hereby give permission for my child’s photographs/videos to be used for educational or promotional purposes, which include but are not limited to, brochures, website and social media. I understand that I can withdraw my consent at any time.
Signature of parent or legal guardian:
Date Signed

Month Day Year
Additional Comments
Payment
$300
Full year tuition:

$0.00

I would like to pay today:Full amount$50.00 minimum$
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