REGISTRATION Register your child for JUDA Kids Club. Full-year and by-month options available. How many children are you registering today?* 1 2 3 Child 1 Name* First Last Hebrew Name DOB* MM slash DD slash YYYY Age*Gender Boy Girl School* Grade Entering*KindergartenFirstSecondThirdFourthFifthSixthSeventhSecond ChildChild 2 Name* First Last Hebrew Name DOB* MM slash DD slash YYYY Age*Gender Boy Girl School* Grade Entering*KindergartenFirstSecondThirdFourthFifthSixthSeventhThird ChildChild 3 Name* First Last Hebrew Name DOB* MM slash DD slash YYYY Age*Gender Boy Girl School* Grade Entering*KindergartenFirstSecondThirdFourthFifthSixthSeventhIs the mother of the child(ren) Jewish? Yes No Do the child(ren)s parents live together? Yes No Parent InformationFather's Name* First Last Hebrew Name Home PhoneFather's Cell*Father's Email* Mother's Name* First Last Hebrew Name Home PhoneMother's Cell*Mother's Email* Home Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Persons to be contacted in case of an emergency when parents cannot be reached. Please provide two contacts.Name 1* First Last Phone*Relationship to child* Name 2 First Last PhoneRelationship to child Does your child attend any special education program?* Yes No Please explain*CONFIDENTIAL: Does your child have any allergies or other medical condition, require medication, or any special abilities or disabilities we should be aware of?* Yes No Please describe them and indicate special precautions or care needed.As the parent(s) or legal guardian of the above child, I/we authorize any adult acting on behalf of Ckids After School to hospitalize or secure treatment for my child, I further agree to pay all charges for that care and/or treatment. It is understood that if time and circumstances reasonably permit, Ckids After School personnel will try, but are not required, to communicate with me prior to such treatment. I hereby give permission for my child to participate in all school activities, join in class and school trips on and beyond school properties and allow my child to be photographed while participating in Ckids After School activities and that these pictures may be used for marketing purposes.* I Accept Name* Initials* Payment Options* Full payment of tuition Scheduled payments by check Credit card payment Monthly credit card payment Other Please check one option.Credit Card American ExpressDiscoverMasterCardVisaSupported Credit Cards: American Express, Discover, MasterCard, Visa Card Number Month010203040506070809101112 Year20262027202820292030203120322033203420352036203720382039204020412042204320442045 Expiration Date Security Code Cardholder Name Amount To Charge* We look forward to a wonderful year of learning and growth! Δ
