Registration for New Attendees - Chabad of Daly City

This form is for new JUDA attendees, if you have previously attended Jewish STEM Club or Super Jew programs please use the returning families enrollment form. Please fill out ALL applicable fields of this form. Payment will only be processed after acceptance. If you have any questions or concerns you'd like to discuss with us, please contact us at: [email protected] or 650-273-6273. No synagogue membership required!
Student Information
Child 1
Student Name*
First Name Last Name
Gender*

FemaleMale
Hebrew name
Birth Date*

Month Day Year
School*
Grade entering*
Previous Jewish Education?*

YesNo
If Yes, please describe
Medical Information - Any Medical Challenges or allergies?*

YesNo
If Yes please explain
Child 2
Student Name
First Name Last Name
Gender

FemaleMale
Hebrew name
Birth Date

Month Day Year
School
Grade entering
Previous Jewish Education?

YesNo
If Yes, please describe
Medical Information - Any Medical Challenges?

YesNo
If Yes please explain
Child 3
Student Name
First Name Last Name
Gender

FemaleMale
Hebrew name
Birth Date

Month Day Year
School
Grade entering
Previous Jewish Education?

YesNo
If Yes, please describe
Medical Information - Any Medical Challenges?

YesNo
If Yes please explain
Parent Information
Father's Full Name*
First Name Last Name
Father's Work Phone Number*

Area Code Phone Number
Father's Cell Phone Number*

Area Code Phone Number
Father's Email*
Father's Occupation
Mother's Full Name*
First Name Last Name
Mother's Work Phone Number*

Area Code Phone Number
Mother's Cell Phone Number*

Area Code Phone Number
Mother's E-mail*
Mother's Occupation
Home Phone Number

Area Code Phone Number

Parent's Address*

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

Are all the parents and grandparents of the child born Jewish?*

YesNo (please specify below)
If applicable, please specify:
Have there been any adoptions or conversions in the family (e.g., the child, parents, grandparents)*

YesNo
If yes, please explain and indicate with which synagogue the conversion took place:
JUDA Kids Enrichment, Super Jew, and Cooking Club are open to children from all backgrounds. I understand that enrollment and acceptance in the JUDA Kids Enrichment or Super Jew or Cooking Club is not a validation of Jewish status.*

Accept
Emergency Contact Information
Full name*
First Name Last Name
Phone Number*

Area Code Phone Number
Relationship*
Full Name*
First Name Last Name
Phone Number*

Area Code Phone Number
Relationship*
Payment Information
Scholarships are available. If a scholarship or rate reduction or payment modifications are needed please email: [email protected] or call 650-278-7576
I am registering for:

1 child JUDA Enrichment Regular Rate $5001 child JUDA Enrichment Reduced Rate $4252 Children - Regular Rate $9002 Children - Reduced Rate $7701 child - 5 sessions of "Dream Building" Israel course Regular Rate $150 (included in JUDA Enrichment program)1 child - 5 sessions of "Dream Building" Israel course Reduced Rate $120 (included in JUDA Enrichment program)
I would like to assist a child who cannot afford Jewish educational enrichment with a donation of:

$
Total

$0.00
Payment plan:*

Please charge my credit card for the full amount at time of acceptance.I will send in one check for the full amount.Please contact me

Payment Method:*

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Credit Card Check

Postal / Zip Code

Country

Disclaimer
As the parent(s) or legal guardian of the above child/ren, I/we authorize any adult acting on behalf of Chabad of Daly City to hospitalize or secure treatment for my/our child/ren, I/we further agree to pay all charges for that care and/or treatment. It is understood that if time and circumstances reasonably permit, Chabad of Daly City personnel will try, but are not required, to communicate with me/us prior to such treatment. I/we hereby give permission for my/our child/ren to participate in all school activities, join in class and school trips on and beyond school properties and allow my/our child/ren to be photographed while participating in Chabad of Daly City activities and for the photos to be used by Chabad of Daly City. I/we also understand that all liability and costs resulting from damage to property and/or personal injury caused or attributable to my/our child/children will be my/our responsibility and I/we agree to fully indemnify and save Chabad of Daly City and its associates, teachers and agents harmless therefrom. I/we consent to Chabad of Daly City's use of our personal information and of our child/children at its discretion in pursuit of school activities. There are no refunds or credits for days missed due to illness, holidays, or family vacations.
Digital Signature
First Name Last Name
I heard about the JUDA Kids Enrichment from:
Comments:
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JUDA KIDS ENRICHMENT

Student Information

Child 1

Child 2

Child 3

Parent Information

Emergency Contact Information

Payment Information

Disclaimer