APPLICANT'S INFORMATION First Name Last Name Hebrew Name D.O.B. Month Jan. Feb. Mar. Apr. May Jun. Jul. Aug. Sept. Oct. Nov. Dec.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 31Year 1996 1997 1998 1999 2000 School Grade Entering Grade Entering Fifth Sixth Seventh Eighth Cell Phone Number Which day of the week works for you? 1st Choice 2nd Choice Previous Jewish Education Yes No If yes - where? PARENT INFORMATION Father's Name Father's Cell Mother's Name Mother's Cell Address City, State, Zip City State Zip Home Phone Email Were there any conversions or adoptions in the family? Yes No If yes, please explain: EMERGENCY INFORMATION Emergency Contact 1 Phone Emergency Contact 2 Phone 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. PAYMENT DETAILS • Club cost for annual membership (10 sessions) is $250, which includes all supplies, materials and trips. Name on card Card Type Select American Express Visa Mastercard Charge Amnt. Card Number Exp. Date Month 01 02 03 04 05 06 07 08 09 10 11 12Year 2011 2012 2013 2014 2015 CVV Code 3 digits on back of card This page uses 128 bit SSL encryption to keep your data secure.