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Bar Mitzvah Enrichment course 2017

Bar Mitzvah Enrichment course 2017

2015 Program

Maps & DirectionsThe Bar Mitzvah Enichment course 2017

To join and find out more about the Bar Mitzvah Enrichment course please contact 
Moshe on 0430 087 879  or email moshe@chabadgleneira.com or complete the form below:

BAR MITZVAH BOY'S INFORMATION
Surname
First Name
Date of Birth (dd/mm/yyyy)
Grade
School
MEDICAL INFORMATION
Any medical conditions
Drug/Food allergies
Is tetanus booster up to date
Is an EPIPEN Required
If your child has an Epipen, please ensure it is brought to every lesson.
 
MOTHERS INFORMATION
Surname
First Name
Email
Home Phone
Mobile
FATHERS INFORMATION
Surname
First Name
Email
Home Phone
Mobile

CHILDS PRIMARY ADDRESS

Street Number & Street Name
Suburb & Postcode
 
Marital Status
Is the natural mother of the child Jewish Yes No
Synagogue affiliation (if any)
 
EMERGENCY INFORMATION
Full Name
Relationship to child
Phone
Mobile
Local GP Name
Local GP Phone
DECLARATION OF PARENT / GUARDIAN
I hereby authorise Chabad House Glen Eira leaders and staff to obtain any medical care necessary for my child. I understand that in the case of emergency of any significant illness or injury, attempt will be made to contact myself when practical. I agree to pay for any cost that may occur as a result of the injury/illness. I acknowledge my child may be participate in activities within and outside the Chabad grounds. I authorise my child to participate in these activities. I hereby authorise Chabad House Glen Eira to photograph my child and to use the photographs at their discretion.
I agree to the above declaration.
Full Name
Date
PAYMENT

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The cost of the Bar Mitzvah enrichment program is $180. There are 18 classes.

   
Card Type  Visa Master Card
Name on card
Card number
Exp
Amount One installment of $180
Two installments of $90 each term

 

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