GROW Registration Returning Children - Chabad of Pinellas County

1. Child/ren’s Information
Number of children being registered:*
Child 1
Name Hebrew Name Last Name
Birth Date*

Month Day Year
Child 2
Name Hebrew Name Last Name
Birth Date*

Month Day Year
Child 3
First Name Hebrew Name Last Name
Birth Date*

Month Day Year
2. Parent information
Mother's info
First Name Last Name
E-mail* Primary email
Cell Phone

Area Code Phone Number
Father's info
First Name Last Name
E-mail
Cell Phone

Area Code Phone Number
What goals do you have for your child attending GROW?
3. Emergency Information
Emergency Contact*
First Name Last Name
Phone Number*

Area Code Phone Number
Doctors Name*
First Name Last Name
Doctors Phone Number*

Area Code Phone Number
Does your child(ren) have any allergies or medical conditions.*
If yes please specify which child and what they are.
Permission for emergency medical treatment*

As the parent or legal guardian, I authorize any adult acting on behalf of GROW to hospitalize or secure treatment for my child. I further agree to pay all charges for that care and/or treatment. It is understood that if time and circumstances reasonably permit, Grow personnel will try, but are not required, to communicate with me prior to such treatment.
4. Payment Information
Tuition: $725/Year, or $75/Month (Members $525)
$50 registration/book fee due at sign up is included in total

Family discounts and scholarships available.

For more information about scholarships or for assistance with a financial plan, please contact Rabbi Pinchas Adler 727 631 7398
Are you a member?*
Choose Your Plan
Plan A - Pay full today $725, Plan B - Pay $50 Today, and then monthly $75 September - May, Plan C - Payment plan discussed with Rabbi Adler
Choose Your Plan
Plan A - Pay full today $525, Plan B - Pay $30 Today, and then monthly $55 September - May, Plan C - Payment plan discussed with Rabbi Adler
Optional Security Donation to Help Cover Security for your children's Safety

$50$75$100

Payment*

Credit Card Check

Total

$0.00
Agreement*

I am signing up my child for GROW. Please charge my card the registration fee or send me a invoice today. I give permission to GROW to photograph and videotape my children and use the photos and videos for advertising purposes.
Please share any other information you feel is important for GROW to be aware of. This can include exceptional behavior, concerns, particular activities, family relationships etc.
Should be Empty:

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1. Child/ren’s Information

2. Parent information

3. Emergency Information

4. Payment Information

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