I would like to register for the Mommy & Me Program at the Chabad of Parkland

Child's First Name:  Last Name: Hebrew Name:  

D.O.B.              Male  Female

Mother's First Name:  Father's First Name:  Last Name:

Address:
     City, ST Zip:

Phone:
 e-mail:  Cell:

Does your child have any allergies? Yes No

If yes, what are they?

Is there another day of the week that would be more convenient for you? 

 

Please check which classes you will be attending :
Entire Session:

I can only attend the selected dates below:

 

 I would like to be a sponsor for $180.

Comments: 

I heard about the Chabad of Parkland Mommy & Me from:

  I will pay in person by check or cash.

Please charge my credit card.
 
 
Name on card:
Card No.

Exp:mm/yyyy  /
CVV Security Code:
What's This? 

Send me confimation via email