Register

Please feel free to call our office with any questions while filling out this form: 914-458-2441
Parent Information
Father's Name*
First NameLast Name
Father's E-mail
Father's Cell
Area CodePhone Number
Mother's Name*
First NameLast Name
Hebrew Name
Mother's Email
Mother's Cell
Area CodePhone Number

Address*

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

Child Information:
Student 1 Name:*
First NameLast Name
Hebrew Name:
Birthdate:*
MonthDayYear
Age:*
Grade Entering:*
Previous Jewish Education
YesNo
If yes - where?
Student 2 Name:
First NameLast Name
Birthdate:
MonthDayYear
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 NameLast Name
Relationship to child(ren)
Phone Number
Area CodePhone Number
Family Physician
First NameLast 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 of Bronxville 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 of Bronxville 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 of Bronxville 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-5:45 pm (includes complimentary dinner) for the duration of the scholastic year.
Tuition:
$750 - full year (includes registration fee, book fee and complimentary dinner)
or $350 - per session
--
$50 sibling discount
Contact the office for the 30% discount for new Aleph Art Room families
I would like to register student 1 for:*
I would like to register student 2 for:$50 sibling discount
I would like to contribute to the Scholarship Fund:
$180
Payment Information:
Total
$0.00

Payment*

Credit Card

Credit Card Type
Credit Card Number
Expiration Month	Expiration Year

Should be Empty:

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Educate Your Child... Educate a Generation

Please feel free to call our office with any questions while filling out this form: 914-458-2441

Parent Information

Child Information:

Medical Information

Registration & Tuition Information:

Payment Information: