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Kivun Kids Club Registration Form 2021-22
Parents' Information
Father's Name*
First NameLast Name
Father's Email*
Father's Cell*
Area CodePhone Number
Father's Work
Area CodePhone Number
Mother's Name*
First NameLast Name
Mother's Email*
Mother's Cell*
Area CodePhone Number
Mother's Work
Area CodePhone Number
Check which apply:*
Mother born JewishMother converted

Address*

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

Family that referred me:
Child's Information
Child: Name*
First NameLast Name
Child Hebrew Name:
Birth Date*
MonthDayYear
Help us figure out the Hebrew birthday!*
born during the dayborn during the eveningborn at dusk/sunset
School*
Does your child have special needs we need to know about?**
YesNo
If yes, please indicate which child, what's the diagnosis, and if he or she has a para
Please list any allergies or medications the child is taking.*
Emergency Information
Doctor's Name*
Phone Number*
Area CodePhone Number
Emergency Contact*
First NameLast Name
Relationship to Child*
Emergency Cell*
Area CodePhone Number
Emergency Home
Area CodePhone Number
Authorized to Pick Up*
ParentEmergency ContactOther
Pick up's Number
Area CodePhone Number
Authorization
I hereby give permission for my child to be transported to and from field trips, and to participate in them in all Kivun activities. I understand that during the course of Kivun my child can be hurt. I accept the risk of possible injury and authorize any member of the Chabad of Bensonhurst staff to render any necessary first aid. Furthermore, in an emergency case, I hereby authorize Chana hertz or another staff member to have my child taken care of by a physcian or other medical person in any way the situation calls for.
Transport/Emergency Care as listed above*
I give permissionI don't give permission
Initial Here
I give permission to Chabad of Bensonhurst and Kivun, and those authorized by Chabad, to take photographs and to make recordings of my children and my family, and to use them in original or modified form in all media now or hereafter known, with or without my name or information about me, for the promotion, public education, and/or fundraising activities of Chabad of Bensonhurst.
Media Authorization*
I give permissionI don't give permission
Initial Here
Payment Options
For other payment options, please call (347) 277-5040
Scholarships Available.
Choose Payment Option:
(If choosing to pay in 2 installments, the second payment will automatically be deducted on January 3rd.)

Payment

Credit Card

Credit Card Type
Credit Card Number	Security Code
Name on Card
Expiration Month	Expiration Year

Billing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Total Amount $
$0.00
Should be Empty:

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Kivun Kids Club Registration Form 2021-22

Parents' Information

Child's Information

Emergency Information

Authorization

Payment Options