Bat Mitzvah Course Enrolment Form

CHILD INFORMATION

Full Name*

First Name Last Name

Hebrew Name*

Date of Birth*

Day Month Year

Student's Email Address

Student's Phone Number

School Attending

School Year (2025)*

Child Primarily lives with

Primary Parent/GuardianSecondary Parent/Guardian

Previous Jewish Education

Is the natural mother of the child Jewish?*

YESNO

Have there been any conversions or adoptions in the family?*

YESNO

AUTHORISATION

I agree that if my child has been injured, or becomes ill whilst at the service or otherwise in care, for a member of the Chabad staff or a nominated supervisor / educator to seek: Medical treatment for the child from a registered medical practitioner, hospital or ambulance service and transportation of the child by an ambulance service*

YESNO

I give consent to the carrying out of appropriate medical, dental or hospital treatment*

YESNO

Does your child have any special considerations we need to take into account for their enrolment?*

YESNO

If Yes, please advise of the special considerations.

MEDICAL CONDITION & DIETARY RESTRICTION

Does your child have any medical management plan, anaphylaxis medical management plan or risk minimisation plan with respect to the child's healthcare need, medical condition or allergy?*

YESNO

If yes, you MUST email a colour copy of your child’s Action Plan to [email protected] and ensure they bring their medication to each lesson.

Does your child have a diagnosed disability?*

YESNO

If Yes, please advise of the diagnosed disability.

ADDITIONAL INFORMATION

Please provide any information you feel we should know about your daughter e.g. language, court orders, additional needs etc.

PARENTS/GUARDIAN DETAILS

PRIMARY PARENT/GUARDIAN

Full Name*

First Name Last Name

Relation to child*

E-mail *

Phone (Mobile)*

Phone (Home)

Address*

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

Authorisation*

EmergencyMedicalSign In / Out

SECONDARY PARENT/GUARDIAN

Full Name*

First Name Last Name

Relation to child*

E-mail*

Phone (Mobile)*

Phone (Home)

Address*

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

Authorisation*

Sign in / outEmergencyMedical

ADDITIONAL/EMERGENCY CONTACTS

(Minimum 2 required)

Please enter additional contacts for this enrolment. This may include emergency contacts when you are unavailable to be contacted in the case of an emergency. E.g for medical authorisations, to authorise staff to remove the child form the facility or for any other emergencies. This may also include authorised nominees who may drop off or pick up this child or authorise excursions.

ADDITIONAL/EMERGENCY CONTACT 1

Full Name*

First Name Last Name

Relation to child*

E-mail*

Phone (Mobile)*

Authorisation*

CollectionEmergencyMedical

ADDITIONAL/EMERGENCY CONTACT 2

Full Name*

First Name Last Name

Relation to Child*

E-mail*

Phone (Mobile)*

Authorisation*

CollectionEmergencyMedical

MEDICAL CONTACTS

Please enter your child's Doctors information. You should enter medical contact here.

Doctor or Practice Name*

First Name Last Name or practice name

Relation to child*

E-mail

Phone (Work)*

Address*

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

Authorisation*

EmergencyMedical

DOCUMENTATION

Please bring-in your original Ketubah or that of your parents (Jewish marriage certificate) and your child’s birth certificate.

CHABAD NORTH SHORE ENROLMENT AGREEMENT

By signing below, I confirm,

I indemnify Chabad North Shore against responsibility for any accident, loss or injury suffered by my child/ren during the course of the activities.

I expressly release Chabad North Shore, its employees or officers from any claim or liability arising directly or indirectly from the enrolled program.

I will pay for the course in full based on the payment plan I select below.

That my child will be photographed and videoed for the purposes of recording the wonderful services we offer, and sharing this information with our parent-body, and for encouraging the attendance of others within our community. If you specifically do not want pictures of video clips of your child/ren shared, please contact Rebbetzin Fruma Schapiro - [email protected] to discuss.

Sign by filling-in your full Legal Name*

SHULE CEREMONY

Most families celebrate their child's Bat Mitzvah with a ceremony in Shule. This is a beautiful chance for all your family, friends and the community to celebrate the Simcha with you.

Shule Ceremony's typically include a Dvar Torah (Rebbetzin Fruma will prepare your daughter for that at an additional charge of $85/lesson) a dedicated speech by the Rabbi to the Bat Mitzvah girl, A siddur presentation, a sponsored kiddush (with the opportunity for the parents to speak) and for Shabbat day celebrations - call-ups to the Torah.

Do you intend on doing a Shule Ceremony at this time?* A cost of $500 to have the Shule ceremony (including Siddur presentation). Free for Members of Cong. Beit Menachem (Chabad's Shule)

YesNoUnsure

If yes / maybe, what would be your service of preference?

Friday NightShabbat MorningUnsure

Please fill in a date if you already have a particular date in mind as your first preference

Day Month Year

MEMBERSHIP INFOMRATION

Members of Congregation Beit Menachem pay $350 less for the course and do not need to pay an additional fee for the Shule service (plus other membership benefits).

Are you currently a Member of Cong. Beit Menachem (Chabad's Shule)

YesNo

Would you like to become a member?

Yes! Please contact me with more informationNot at the moment, but may be interested at a later stageNo

PAYMENT INFORMATION

The Bat Mitzvah Course costs $1350 ($1000 for members of Congregation Beit Menachem - Chabad's Shule) A deposit of $250 is taken upon registration. The money will go towards the fees of the course. The remainder of the payment is charged based on the payment plans you choose below.

($100 off the course for deposits made before 29 September 2024)

Payment Options*

Pay the remaining $1100 today (or $750 for Cong. Beit Menachem members)Pay the remainder in 2 instalmentsPay the remainder in 3 instalmentsI would like to speak to someone about an alternative payment plan

Payment Method*

Direct DebitCredit Card (Surcharge of 1.1% Mastercard, 1.5% VIsa and 2% Amex)

*

Credit Card

We accept Visa, MasterCard, American Express
Credit Card Number
Expiration Month	Expiration Year

Bank:*

Account Name:*

BSB:*

Account Number:*

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