Jewish Kids club

Address*

Father's E-mail*
Mother's E-mail*
*
I hereby give permission for my child to be photographed. Photos may be used for promotional purposes for Chabad of West Davie
Medical Emergencies:
Emergency Contact
Phone Number
Medical Emergencies*
I authorize the staff of Chabad to seek appropriate medical care for my child, if necessary. As the parent(s) or legal guardian we authorize any adult acting on behalf of Chabad to hospitalize or secure treatment for my child, I further agree to pay all charges for that care and/or treatment.
Relationship To Child
Payment Information:
Payment*
$20
Total
$0.00 USD

Payment Method*

Credit Card

We accept Visa, MasterCard, American Express, Discover
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

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