Register

Kivun Registration Form 2020-21
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 the West Side 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
Schedule and Payment Options
Sibling Discount: 10% sibling discount for 2nd and 3rd children in the same family
Ambassador Discount: Get another family to register for Kivun, you will get $50 off your tuition!
Payment:
$300 for January 2021 - June 2021
Deduct 10% of total for second and third child
Scholarships Available - Please call 347.277.5040

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

Should be Empty:

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Kivun Registration Form 2020-21

Parents' Information

Child's Information

Emergency Information

Authorization

Schedule and Payment Options