JUDA registration form - chabadofislip.com

Did your child attend JUDA in 2023-24?*

YesNo

We will use your child's info from your previous registration. If anything changed please inform us at [email protected]

Please fill out the rest of registration below:

CHILD INFORMATION

Full Name*

Hebrew Name

Birth Date*

Month Day Year

School Attending*

Current Grade*

Is your child taking permanent medications?*

YesNo

Any known allergies*

YesNo

Any present medical conditions?*

YesNo

Any learning disabilities?*

YesNo

If you answered yes to any of the questions above, please provide details:

Register a 2nd child?*

YesNo

CHILD 2 INFO:

Full Name*

Hebrew Name

Birth Date*

Month Day Year

School Attending*

Current Grade*

Is your child taking permanent medications?*

YesNo

Any known allergies*

YesNo

Any present medical conditions?*

YesNo

Any learning disabilities?*

YesNo

If you answered yes to any of the questions above, please provide details:

Register a 3rd child?

YesNo

CHILD 3 INFO:

Full Name*

Hebrew Name

Birth Date*

Month Day Year

School Attending*

Current Grade*

Is your child taking permanent medications?*

YesNo

Any known allergies*

YesNo

Any present medical conditions?*

YesNo

Any learning disabilities?*

YesNo

If you answered yes to any of the questions above, please provide details:

PARENT INFORMATION

Parent's Marital Status*

Is the natural mother of the child Jewish?*

YesNo

Have there been any conversions or adoptions in the family?*

YesNo

If yes, please specify Rabbi & Congregation

Parent 1 Full Name*

First Name Last Name

E-mail*

Home Phone Number*

Area Code Phone Number

Cell Phone Number*

Area Code Phone Number

Parent 2 Full Name*

First Name Last Name

E-mail*

Home Phone Number*

Area Code Phone Number

Cell Phone Number*

Area Code Phone Number

Home Address*

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

EMERGENCY CONTACT INFO

Full Name*

First Name Last Name

Phone Number*

Area Code Phone Number

Relation*

PROGRAM & TUITION AGREEMENT:

I hereby confirm my child’s enrollment in The Chabad of Islip JUDA Program.

I represent that I am the custodial parent or legal guardian of the child that I am enrolling and that the information I have provided is true and correct.

I fully understand that this enrollment, as part of my commitment to a long-term Jewish education at JUDA, is accepted only on the basis of the full program, and agree to pay the full spring session fee accordingly. I understand that no refunds or adjustments will be made for absences including, but not limited to, illness or vacation.

I agree to the following Fees:

$1,000 for September 2024-May 2025 School year.

5% discount for additional children in same family

5% discount for referring a new family

50% of payment due upon registration. Full payment due by December 31st 2024.

Disclaimer
Accident: As the parent(s) or legal guardian of the above child/ren, I/we authorize any adult acting on behalf of JUDA 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, JUDA/Chabad of Islip personnel will try, but are not required, to communicate with me prior to such treatment.

Privacy: I hereby give permission for my child’s photographs/videos to be used in newsletters, local newspapers, The Chabad of Islip and JUDA website or for promotion of our program.

Digital Signature of Parent *

PAYMENT

*

Credit Card Paypal Check/Cash/Scholarship

Amount to charge*

Full payment for 1st Child $1,00050% of payment for 1st Child $500Full payment for 2nd Child +$95050% of payment for 2nd Child $475Full payment for 3rd Child +$95050% of payment for 3rd Child $475Please email me about available scholarships

Total

$0.00