Name of Child #1: Age:

Birth Date:

Hebrew Name:

Name of Day School: Grade:

Name of Child #2: Age:

Birth Date:

Hebrew Name:

Name of Day School: Grade:

Name of Child #3: Age:

Birth Date:

Hebrew Name:

Name of Day School: Grade:

Mother Address:

Father Address (if different):

Mother Cell: Email:

Father Cell: Email:

Mother's Hebrew/English Name:

Father's Hebrew/English Name:

Is the biological mother Jewish by birth? yes no

Is the biological father Jewish by birth? yes no

Has there been a conversion or adoption in the family or extended family?
If yes, please specify:

Does your child(ren) have any learning challenges:

Any medical condition regarding your child(ren) we should be aware of:

Emergency Contact:

Phone:

Please enroll our child(ren) in the Jewish Kids Club

In the event of a medical emergency and neither parent can be reached, medical treatment may be provided as necessary.

I (we) hereby permit my child(ren) to participate in all school activities, join in class and school trips on and beyond school properties.

I (we) hereby allow my child(ren) to be photographed while participating in the Chabad Jewish Kids Club activities and that these pictures may be used for marketing purposes.

Name:

Initials:

Membership: $500 for full year • Second child: $400

Please charge my credit card full payment for the year: $

Four monthly payments of $

Credit Card Number: Exp.  CVV   

Will pay by check

We look forward to a wonderful year of learning and growth!