Registration for New Club Members

This form is for new Jewish STEM Club members, if you are re-enrolling a member please click here

Please fill out ALL applicable fields of this form.

Depending on interest, we may also offer a younger class for children ages 4-6. If you are interested in the younger class, please fill out the form, and we will contact you to let you know if it will be available for this year.

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: info@jewishdalycity.com or 650-273-6273.
No synagogue membership required!
Student Information
Child 1
Student Name*
First NameLast Name
Gender*
FemaleMale
Hebrew name
Birth Date*
MonthDayYear
School*
Grade entering*
Previous Jewish Education?*
YesNo
If Yes, please describe
Medical Information - Any Medical Challenges?*
YesNo
If Yes please explain
Child 2
Student Name
First NameLast Name
Gender
FemaleMale
Hebrew name
Birth Date
MonthDayYear
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 NameLast Name
Gender
FemaleMale
Hebrew name
Birth Date
MonthDayYear
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 NameLast Name
Father's Work Phone Number*
Area CodePhone Number
Father's Cell Phone Number*
Area CodePhone Number
Father's Email*
Father's Occupation*
Mother's Full Name*
First NameLast Name
Mother's Work Phone Number*
Area CodePhone Number
Mother's Cell Phone Number*
Area CodePhone Number
Mother's E-mail*
Mother's Occupation*
Home Phone Number*
Area CodePhone 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:
Jewish STEM club is open to children from all backgrounds. I understand that enrollment and acceptance in the Jewish STEM Club is not a validation of Jewish status*
Accept
Emergency Contact Information
Full name*
First NameLast Name
Phone Number*
Area CodePhone Number
Relationship*
Full Name*
First NameLast Name
Phone Number*
Area CodePhone Number
Relationship*
Payment Information
Scholarships are available. If a scholarship or rate reduction or payment modifications are needed please email: rabbi@chabadnorthcounty.com or call 650-278-7576
I am registering for:*
1 Child - $6752 Children - $13503 Children - $2025
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.Please charge my credit card $175 at time of acceptance and then $125 in four installments - Oct 1, Dec 1, Feb 1 and April 1.I will send in one check for the full amount.I will send in one check for $175 with additional checks each for $125 postdated for Oct 1, Dec 1, Feb 1 and April 1.

Payment Method:*

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. 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. Refunds for children withdrawing from school before the end of the school year will be pro-rated up to February 1 provided that the school office is given 30 days written notice and does not include the registration fee. Tuition refunds will not be granted to children withdrawing from school after February 1. There are no refunds or credits for days missed due to illness, holidays, or family vacations.
Digital Signature
First NameLast Name
I heard about the Jewish STEM Club from:
Comments:
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Jewish STEM Club

Student Information

Child 1

Child 2

Child 3

Parent Information

Emergency Contact Information

Payment Information

Disclaimer

Jewish
STEM
Club