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Chai Five Registration 2023-24
Please verify reCaptcha before submitting the form.
*
Student First Name
*
Student Last Name
*
Address
*
City
*
State
--Select State--
Alabama
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District of Columbia
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Vermont
Virginia
Washington
West Virginia
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*
Zip
*
Student Cell Phone Number
*
Student Email Address
*
Student Date of Birth
*
Student Grade
Please Select One
8th
9th
10th
11th
12th
*
School Name
*
Class Enrolling In
Please Select One
8th and 9th Graders - B'Yachad
10th and 11th Graders - Confirmation
USY Member - 11th and 12th Graders - Senior Seminar
NON USY Member - 11th and 12th Graders - Senior Seminar
USY Member - 11th Confirmation and Senior Seminar
NON USY Member - 11th Confirmation and Senior Seminar
If you are an 11th grader and you are signing up for both Confirmation and Senior Seminar please pay close attention to drop down selections.
If you are in need of financial assistance,
please contact
Rabbi Adler.
*
Parent/Guardian First Name
*
Parent/Guardian Last Name
*
Parent/Guardian Cell Phone Number
*
Parent/Guardian Email Address
Please send Chai Five communications to this email address
Please send Chai Five communications to this email address
*
If there is a second parent/guardian, please select Yes.
Please Select One
Yes
No
Parent/Guardian 2 First Name
Parent/Guardian 2 Last Name
Parent/Guardian 2 Cell Phone Number
Parent/Guardian 2 Email Address
Please send Chai Five communications to this email address
Please send Chai Five communications to this email address
EMERGENCY MEDICAL AUTHORIZATION
Should my child suffer an injury or illness while in the care of Etz Chaim Religious School and the facility is unable to contact me (us) immediately, it shall be authorized to secure such medical attention and care as may be necessary.
I (We) shall assume responsibility for payment for services.
My child will be transported to Children’s Healthcare of Atlanta at Scottish Rite.
*
Please type your name here as your signature and acknowledgement of the emergency medical authorization
2nd Parent/Guardian (if applicable) - Please type your name here as your signature and acknowledgement of the emergency medical authorization
TOTAL
Sat, July 27 2024 21 Tammuz 5784