Please feel free to call our office with any questions while filling out this form: 914-458-2441Parent InformationFather's Name*First NameLast NameFather's E-mailFather's CellArea CodePhone NumberMother's Name*First NameLast NameHebrew NameMother's EmailMother's CellArea CodePhone NumberAddress*Street AddressStreet Address Line 2CityState / ProvincePostal / Zip CodePlease SelectUnited StatesAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanThe BahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChilePeople's Republic of ChinaRepublic of ChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCook IslandsCosta RicaCote d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonThe GambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNagorno-KarabakhNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandTurkish Republic of Northern CyprusNorthern MarianaNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint BarthelemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSomalilandSouth AfricaSouth OssetiaSpainSri LankaSudanSurinameSvalbardSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTransnistria PridnestrovieTrinidad and TobagoTristan da CunhaTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamBritish Virgin IslandsUS Virgin IslandsWallis and FutunaWestern SaharaYemenZambiaZimbabweOtherCountryChild Information:Student 1 Name:*First NameLast NameHebrew Name:Birthdate:*MonthDayYear Age:*Grade Entering:*Previous Jewish EducationYesNoIf yes - where?Student 2 Name:First NameLast NameBirthdate:MonthDayYear Age:Grade Entering:Previous Jewish EducationYesNoIf yes - where?Is the natural mother of the Child(ren) Jewish?*YesNoWere there any conversions or adoptions in the family?*YesNoIf yes, please explainComments/NotesMedical InformationPersons to be contacted in case of an emergency when parents cannot be reached: (Please provide at least two contacts)Emergency ContactFirst NameLast NameRelationship to child(ren)Phone NumberArea CodePhone NumberFamily PhysicianFirst NameLast NamePhysician PhoneCONFIDENTIAL: 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 agreeName*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:*Winter Session ($350/session)Spring Session ($350/session)I would like to register student 2 for:$50 sibling discountWinter Session ($300/session)Spring Session ($300/session)I would like to contribute to the Scholarship Fund:$180Payment Information:Total$0.00Payment*Credit CardVisaMasterCardAmerican ExpressDiscoverCredit Card TypeCredit Card Number1 - January2 - February3 - March4 - April5 - May6 - June7 - July8 - August9 - September10 - October11 - November12 - DecemberExpiration Month2019202020212022202320242025202620272028Expiration YearSubmitShould be Empty: This page uses TLS encryption to keep your data secure.