BMC Club Registration Form 5778

Cost for the program for the year: $300
Chabad Members: $270

Filling out form does not mean acceptance, applicants are accepted based on first come first served basis, based on limited space available.
Student Profile
First Name
Last Name
Hebrew Name
Grade Entering
Name of Shull affiliated with
Date of Bat Mitzvah Party (if known)
Parent Information
Email Address
(checked daily)
Father's Name
Father's Cell
Mother's Name
Mother's Cell
Emergency Information
Emergency Contact 1
Emergency Contact 2
Doctor's Name
Doctor's Phone Number

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 5 Towns 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 5 Towns 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 school activities, join in class and school trips on and beyond school properties and allow my child to be photographed while participating in all activities and that these pictures may be used for marketing purposes.

I Accept

Should you wish to pay online


This page uses a secure connection and your information will not be shared with anyone.
Online Payment
Payment Chabad member $270 Non member $300
Amount: $
Card Number
Last Name
Card Type
Exp. Date
I understand that my money is not refundable.
I heard about this program from:
I give permission for my child’s photo to be used in newspapers / Web etc...