JUDA! The Jewish Fun Zone
Registration 2021-22  

MONDAYS, 4:30-6:00 PM*
Beginning Monday, August 30
Girls and Boys Ages 5-13
ONLY $495 for full year per child (includes registration, books, and supplies!)
Additional 10% off for siblings 

Please fill out ALL fields of this form. If you have any questions or concerns you'd like to discuss with us, please contact us.

Please note that one registration form per child is needed.

We look forward to a wonderful year of learning, growth, and fun!    

Student Profile
First Name
Last Name
Hebrew Name
Age
DOB		Month   Jan.   Feb.   Mar.   Apr.   May   Jun.   Jul.   Aug.   Sept.   Oct.   Nov.           Date   1   2   3   4   5   6   7   8   9   10   11   12   13   14   15   16   17   18   19   20   21   22   23   24   25   26   27   28   29   30   31          1989   1990   1991   1992   1993   1994   1995   1996   1997   1998   1999   2000   2001   2002   2003   2004   2005   2006   2007   2008   Year
School
Grade Entering		first   second   third   fourth   fifth   sixth   seventh
Hebrew Reading Proficiency		None     Somewhat     Well
Previous Jewish Education		Yes             No
Where?

Family Information

My child is a    Kohen   Levi   Yisroel   Not sure

Are the natural father and mother of the child Jewish?  Yes  No If no, please explain.

Have there been any conversions or adoptions in the family?  Yes  No If yes, please explain.

Are you interested in carpooling?   Yes  No If yes, can we give your number to other parents?  Yes  No

Parent Information
Father's Name
Mobile
Mother's Name
Mobile
Home Phone
Address
City
Zip
Email*
* Email address allows us to communicate in the most efficient and economical manner. We do not use your address for other purposes.

Emergency Information
Emergency Contact 1
Phone
Relationship
Emergency Contact 2
Phone
Relationship

 

CONFIDENTIAL:  Does your child have any allergies or other medical condition we should be aware of?  If yes, please describe them and indicate special precautions or care needed. 

Tuition Agreement 
$495 for first child (includes registration, books, and supplies)
*There is a 10% discount for siblings (child number 2, 3, and 4) 

 I will pay the full amount by check/credit card

 I would like to pay in monthly installments (Divide the total amount by 10, and your credit card will be billed monthly)

**No child will be turned away due to lack of funds. Please contact us if you need further financial assistance. 

Terms of Agreement

In the event of an emergency, JUDA! has my permission to arrange for any necessary first-aid or care by a licensed physician/first-aid worker. JUDA! has my permission to use my child's photo in its publicity materials. I have completed the Enrollment Form and agree to pay any balance according to the terms of agreement outlined above.

I Accept   

Name:      Initials:

We look forward to a wonderful year of learning and growth!