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Chabad Youth Programming Chessed Club 5786

Chessed Club Online Registration

Chessed Club 2025/26 REGISTRATION
CHILD INFORMATION
Child's Name*
First Name Last Name
Child's Birthday*

Month Day Year
Child's Age *
School*
Grade*
Please list any allergies that your child may have.
PARENT INFORMATION
Parent's Name (1)*
First Name Last Name
Parent's Home Phone (1)*

Area Code Phone Number
Parent's Cell Phone (1)*

Area Code Phone Number
Parent's Email Address (1)*
Parent's Name (2)
First Name Last Name
Parent's Cell Phone (2)

Area Code Phone Number
Comments/Questions:
The cost to enroll in this program is $150.
Click to verify Full Payment of $150

$150
Check if you would like to sponsor another child for this club.
Total

$0.00

Payment

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

City

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Postal / Zip Code

Country

Signature *
For any questions or concerns please text Chaya Rochel at (516)-592-2384.
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