Child InformationFirst Name *Middle NameLast Name *Hebrew Name *Hebrew Date of BirthDate of Birth *DaySelect day12345678910111213141516171819202122232425262728293031MonthSelect month123456789101112YearSelect Year212321222121212021192118211721162115211421132112211121102109210821072106210521042103210221012100209920982097209620952094209320922091209020892088208720862085208420832082208120802079207820772076207520742073207220712070206920682067206620652064206320622061206020592058205720562055205420532052205120502049204820472046204520442043204220412040203920382037203620352034203320322031203020292028202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923SchoolPlease List any Prior Jewish Education *Is the natural mother of the child Jewish? *YesNoPlease Upload Proof of Jewish Identity (e.g. Ketubah, Birth Certificate etc.)Choose FileNo file chosenDelete uploaded filePlease Upload Certificate of ConversionChoose FileNo file chosenDelete uploaded fileHave there been any conversions or adoptions in the family? *YesNoADDITIONAL INFORMATIONPlease provide any information you feel we should know about your child e.g. language, court orders, additional needs etc.PRIMARY PARENT/GUARDIANPrefixMr.Mrs.Ms.Mx.MissDr.Prof.First Name *Middle NameLast Name *Relation to Child: *Email Address *Phone (Mobile) *Phone (Landline)Street Address *Apartment, suite, etcCity *State/Province *ZIP / Postal Code *Authorisation: *EmergencyMedicalSign In / OutSECONDARY PARENT/GUARDIANPrefixMr.Mrs.Ms.Mx.MissDr.Prof.First Name *Middle NameLast Name *Relation to Child: *Email Address *Phone (Mobile) *Does Address Differ From PRIMARY PARENT/GUARDIAN? *YesNoStreet AddressApartment, suite, etcCityState/ProvinceZIP / Postal CodeAuthorisation: *EmergencyMedicalSign In / OutPlease Enter Your Full Legal Name Here: *Please Sign Here: *Start signing your signature hereYour browser does not support e-Signature field.If you are not able to make the donation, please contact us at: Office@chabad.nzDonation ($500.00) *Bank TransferCredit / Debit CardCredit / Debit Card *Bank Information for Transfer:Account Number: 060145036883400 YOUR DONATION IS TAX DEDUCTIBLE.Please Upload Receipt of Donation *Choose FileNo file chosenDelete uploaded fileSubmit
