BMX eXperience - JewishHighlands.com

BMX PARTICIPANT PROFILE

First Name*

Last Name*

Hebrew Name If your child does not have a Hebrew name, please leave blank.

Birth Date*

Month Day Year

School *

Grade Entering*

Previous Jewish Education*

YesNo

If yes, where?

Are there any conversions in the family?* Including any parent or grandparent. If yes, please indicate the relationship to the child.

PARENT INFORMATION

Mother's Name*

Mother's Phone*

Mother's Email*

Was Child's Mother Born Jewish?*

YesNo

Was Child's Mother's Mother (Maternal Grandmother) Born Jewish?*

YesNo

Father's Name*

Father's Phone*

Father's Email*

Is Child's Father Jewish?*

YesNo

Address*

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

E-mail*

I would like to receive news and updates by email

EMERGENCY INFORMATION
If parents are unable to be reached.

Emergency Contact 1*

Phone Number*

Area Code Phone Number

Emergency Contact 2

Phone Number

Area Code 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.

PAYMENT INFORMATION

$699 Per Child

Number of participants registering

Total

$0.00

Payment Plan

Pay in full at this timePayments will be divided over two monthsI would like to discuss the option of a partial scholarshipI have already discussed scholarship options

Please note: All credit card payments will include a 3% processing fee. If you would like to pay by check please indicate it in the box below. If paying by check, credit card information is still required on the form, but will not be processed.

*

I will pay by Credit Card.I will pay by Check in full before September 8.I will pay by Check in two installments. Two predated checks are required, dated September 8 and January 8.

Payment* Payment will only be processed manually based on your selection above

Credit Card Check

Postal / Zip Code

Country

As the parent(s) or legal guardian of the above child, I/we authorize any adult acting on behalf of Chabad Center for Jewish Life to hospitalize or secure treatment for my child, I further agree to pay all charges for that care and/or treatment. Chabad Center for Jewish Life personnel will communicate with me prior to any such treatment. I hereby give permission for my child to participate in all BMX activities, join in class and school trips on and beyond school properties. I allow my child to be photographed while participating in BMX activities and that these pictures may be used for marketing purposes.

*

Accept

Name*

Initials*

We look forward to a great year full of memorable experiences!

Register Online