Junior Aleph Bet Reservation Form

Personal Information

Name of child:  Age: 

Hebrew Name: 

Birthday: 

Address: 

Phone number:  Cell: 

Mothers Hebrew / English name : 

Fathers Hebrew / English name: 

Name of School : 

E-mail: 

Child's Medical Information

Doctor:  Phone number: 

Address 

Allergies or other medical conditions: 

Emergency Contact

Emergency contact: Phone Number:

In the event of a medical emergency and neither parent can be reached, Medical treatment may be provided as necessary.

 I (we) hereby enroll our child in the Junior Aleph bet Program.

My (our) child may be photographed and Chabad may use the pictures for publication

Payment

If you wish to pay by credit card, please fill out the information below:

Credit Card Type:
Credit Card #:
Expiration Date:  
CC Authorization: Yes, I authorize Chabad to charge my credit card.
Email Confirmation:
Notes:



 I will be mailing a check to Chabad of Barrington  at 311 Maple Avenue, Barrington RI 02806

I would like to be added to the mailing list.