Printed from BaisChabad.com

Register

Register

We are currently accepting application forms for Aleph Art Room 2016-2017 and Kids for Kindness Spring 2017.

Please fill out ALL fields of this form. If you have any questions or concerns you'd like to discuss, please contact us at 248-865-1541 or zeesy@baischabad.com.

STUDENT INFORMATION
First Name
Last Name
Hebrew Name
Don't have one? We can help!
D.O.B.
Jewish Education Current / Previous Yes No
If yes, where?
Siblings names & ages
i.e. Daniel 7, Abigail 4, Jonathan 1
Is there any information concerning your child that is important for the directors of Bais Chabad Youth Zone to know?
Does your child have asthma, food allergies or any other medical condition? Yes No
Do you give permission to use photographs of your child in print materials,
on our website and emails? Yes No
All information submitted is strictly confidential and never shared with anyone and is only seen by the teachers of the said program.
PARENT INFORMATION
Father's Name Father's Email
Mother's Name Mother's Email
Address City, State, Zip
Home Phone Mother's Cell
SESSION REGISTRATION

My child will be attending

 

Aleph Art Room! (ages 4-12)

Spring Session: $80 (5 lessons)

Full Year Tuition $320 (19 lessons)

PAYMENT
First Name
Last Name
Charge Amount
Card Type
Card Number
Exp. Date
CVV Code 3 digits on back of card
I prefer to send a check and will mail it to you.

Secure This page uses 128 bit SSL encryption to keep your data secure.

Upcoming Events
There are no events posted at this time. Please contact us for more info about our events.