Kids Club Registration 2024-2025

Registration 2024-2025 / 5785
Note: this form can register up to two children; to enroll three or more, please call Esther at (505) 577-6071
Name of Child (1)*

First Name Last Name
Age (4-12)*
Birth Date*

Month Day Year
Hebrew Name
Name of School*
Grade*

Pre-K / Kindergarten
Register a second child?*

YesNo
Name of Child (2)

First Name Last Name
Age (4-12) (Child 2)
Birth Date (Child 2)

Month Day Year
Hebrew Name (Child 2)
Name of School (Child 2)
Grade (Child 2)

Pre-K / Kindergarten
Mother Full Name*

First Name Last Name
Mother Address*
Father Full Name*

First Name Last Name
Father Address (if different)
Mother Cell*
Mother E-mail*
Father Cell*
Father E-mail*
Mother's Hebrew Name
Father's Hebrew Name
Is the biological mother Jewish by birth?*

YesNo
Is the biological father Jewish by birth?*

YesNo
Has there been a conversion or adoption in the family / extended family?* If yes, please specify
Does your child have any learning or behavioral challenges or have an IEP at school?* By sharing this information, you help us help your child
Does your child have any allergies or medical conditions we should be aware of?*
Notes and Comments
Emergency Contact Name*

First Name Last Name
Emergency Contact Phone*
Relationship to Child*
Please Confirm*

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 Hochberg Jewish Kids Club activities and that these pictures may be used for marketing purposes.
Name*
Initials*
Membership cost is $600 for full year • Second child $500
You may choose to pay in full up front, or in 4 equal installments of 25% (paid in first 4 consecutive months)
Payment Options (one child)* Please Select: Full Payment or First of 4 Monthly Installments of $150

$600$150
Payment Options (two children)* Please Select: Full Payment or First of 4 Monthly Installments of $275

$1100$275
Total

$0.00

Form of Payment*

Credit Card Check

Postal / Zip Code

Country

Should be Empty:

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Kids Club Registration 2024-2025

Registration 2024-2025 / 5785

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