Child Information    
Child 1    
Last Name
First Name
Hebrew Name
Date of Birth
Age
 
What school does your child attend? Grade entering:
 
Child 2    
Last Name
First Name
Hebrew Name
Date of Birth

Age

 
What school does your child attend? Grade entering:
 
Child 3    
Last Name
First Name
Hebrew Name
Date of Birth
Age
 
What school does your child attend? Grade entering:
 
     

Parent Information

   
Mother's Name
Home Phone

Work Phone

Cell Phone
Email
Occupation
Address
City
State
Zip
   
Father's Name
Home Phone
Work Phone
Cell Phone
Email
Occupation
Address (if different than above)
City
State
Zip
   
     
I heard about Chai Five from:
     
Chai Five Payment    
The cost for Chai Five is $180.00 per year
Credit Card Information
First Name Last Name
Credit Card Number Billing Address
City State, Zip
Charge Amount Exp Date
CVV    

I will send a check to Chabad of Potomac,. 11621 Seven Locks Rd., Potomac, MD 20854:

We Look Forward to a Fun Filled and Enriching Program!