APPLICANT'S INFORMATION
First Name   Last Name
Hebrew Name   D.O.B.
School   Grade Entering
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
Charge Amnt.   Card Number
Exp. Date   CVV Code   3 digits on back of card