Please feel free to call Mrs. Mushka Deitsch with any questions while filling out this form: 914-458-2441 Parent Information Father's Name* First Name Last Name Father's E-mail Father's Cell Area Code Phone Number Mother's Name* First Name Last Name Mother's Hebrew Name Mother's Email Mother's Cell Area Code Phone Number Address* Street Address Street Address Line 2 City State / Province Postal / Zip Code Please Select United States Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan The Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Brazil Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile People's Republic of China Republic of China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Cote d'Ivoire Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Eswatini Ethiopia Falkland Islands Faroe Islands Fiji Finland France French Polynesia Gabon The Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati North Korea South Korea Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Islands Poland Portugal Puerto Rico Qatar Romania Russia Rwanda Saint Barthelemy Saint Helena Saint Kitts and Nevis Saint Lucia Saint Martin Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia Somaliland South Africa South Ossetia Spain Sri Lanka Sudan Suriname Svalbard Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tristan da Cunha Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam British Virgin Islands US Virgin Islands Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe Other Country Child Information: Student 1 Name:* First Name Last Name Hebrew Name: Birthdate:* Month Day Year Age:* Grade Entering:* Previous Jewish Education YesNo If yes - where? Student 2 Name: First Name Last Name Birthdate: Month Day Year Age: Grade Entering: Previous Jewish Education YesNo If yes - where? Is the natural mother of the Child(ren) Jewish?* YesNo Were there any conversions or adoptions in the family?* YesNo If yes, please explain Comments/Notes Medical Information Persons to be contacted in case of an emergency when parents cannot be reached: (Please provide at least two contacts) Emergency Contact First Name Last Name Relationship to child(ren) Phone Number Area Code Phone Number Family Physician First Name Last Name Physician 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. As the parent(s) or legal guardian of the above child, I/we authorize any adult acting on behalf of Chabad Jewish Center Aleph Art Room program 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 Jewish Center Aleph Art Room program personnel will try, but are not required, to communicate with me prior to such treatment. I hereby give permission for my child to participate in all program activities, join in class and school trips on and beyond the program properties and allow my child to be photographed while participating in Chabad Jewish Center Aleph Art Room activities and that these pictures may be used for marketing purposes. * I agree Name* Initials* Registration & Tuition Information: Times: Wednesday 4:00 pm-5:30 pm for the duration of the scholastic year. Tuition: $950 - full year -- $50 sibling discount Contact Rabbi Sruli Deitsch 914.458.2441 to inquire about scholorships. Registration:* Pay in Full - $950Pay in 3 Installments - $316.66Pay in full with sibling discount - $900Pay in 3 Installments with sibling discount - $300 I would like to register student 1 for: Winter Session ($350/session) Spring Session ($350/session) I would like to register student 2 for: $50 sibling discount Winter Session ($300/session) Spring Session ($300/session) I would like to contribute to the Scholarship Fund: $180 Payment Information: Total $0.00 Payment* Credit Card We accept Visa, MasterCard, American Express, Discover Credit Card Number 1 - January 2 - February 3 - March 4 - April 5 - May 6 - June 7 - July 8 - August 9 - September 10 - October 11 - November 12 - December Expiration Month 2023 2024 2025 2026 2027 2028 2029 2030 2031 2032 Expiration Year Submit Should be Empty: This page uses TLS encryption to keep your data secure.