Jscouts - Monthly Mitzvah Club - Lubavitch Chabad of Northbrook

Address*

Gender*

MaleFemale
Hebrew Name Example: David or דוד
Childs Birth Date*

Month Day Year
What time of day was your child born?

Before sunsetAfter SunsetUnkown
Grade Entering*
Childs School
Parent/Guardian Information
Name*
First Name Last Name
E-mail*
Phone Number*
*

I hereby consent to the administration of Chabad of Northbrook to take whatever medical measures they deem necessary for my child in the event of a medical emergency.
*

I hereby give permission for my child to participate in all JScouts activities, including trips and activities on and off Chabad property. I give permission for my child to be photographed during JScouts, and for these photos to be used for promotional and marketing purposes.
Emergency Contact
Name*
First Name Last Name
Phone Number*
Early Bird Price* (Before September 17)

$239
Total (Early Bird Pricing)

$239.00

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

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Jscouts - Monthly Mitzvah Club