CHILD INFORMATION Full Name* First Name Last Name Hebrew Name* Date of Birth* 12345678910111213141516171819202122232425262728293031 Day1 - January2 - February3 - March4 - April5 - May6 - June7 - July8 - August9 - September10 - October11 - November12 - December Month202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 Year Student's Email Address Student's Phone Number School Attending School Year (2025)* Year 6Year 7 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 CodePlease SelectUnited StatesAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanThe BahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChilePeople's Republic of ChinaRepublic of ChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCook IslandsCosta RicaCote d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonThe GambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern MarianaNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint BarthelemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSomalilandSouth AfricaSouth OssetiaSpainSri LankaSudanSurinameSvalbardSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTristan da CunhaTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamBritish Virgin IslandsUS Virgin IslandsWallis and FutunaWestern SaharaYemenZambiaZimbabweOther Country 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 CodePlease SelectUnited StatesAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanThe BahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChilePeople's Republic of ChinaRepublic of ChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCook IslandsCosta RicaCote d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonThe GambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern MarianaNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint BarthelemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSomalilandSouth AfricaSouth OssetiaSpainSri LankaSudanSurinameSvalbardSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTristan da CunhaTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamBritish Virgin IslandsUS Virgin IslandsWallis and FutunaWestern SaharaYemenZambiaZimbabweOther Country DOCUMENTATIONPlease 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 A Shule ceremony is a wonderful opportunity to celebrate this occasion with family, friends and the community. At Chabad, we will prepare your child for a beautiful Shule Ceremony which my include a call up to the Torah, reading a portion of the Torah / Haftorah, leading services, a Dvar Torah among other options. There will also be a dedicated speech by the Rabbi to the Bar Mitzvah boy, A siddur presentation, a sponsored kiddush (with the opportunity for the parents to speak) and the opportunity for other members of the family to be called up to the Torah. Rabbi Mendy will prepare your son for his Bar Mitzvah at an additional cost of $35/half hour lesson. For those who are not members of Cong. Beit Menachem, there are additional costs of $500 for the Shule Ceremony. If you have not yet booked in your date, what is your Shabbat of preference? Day Month Year MEMBERSHIP INFOMRATION Members of Congregation Beit Menachem pay $200 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 thank you PAYMENT INFORMATION The Bar Mitzvah Course costs $1000 ($800 for members of Congregation Beit Menachem - Chabad's Shule). A deposit of $200 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. All private lessons will be charged to the same payment details 4 weeks in advance. Payment Options* Pay the remaining $800 today (or $600 for Cong. Beit Menachem members)Pay the remainder in 2 instalments on 7 April & 7 MayPay the remainder in 3 instalments on 7 April, 7 May & 7 JuneI 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) * ⚠ You have not yet connected a credit card processor.Credit Card We accept Visa, MasterCard, American Express Credit Card Number1 - January2 - February3 - March4 - April5 - May6 - June7 - July8 - August9 - September10 - October11 - November12 - December Expiration Month2024202520262027202820292030203120322033 Expiration Year Bank:* Account Name:* BSB:* Account Number:* Submit Should be Empty: This page uses TLS encryption to keep your data secure.