MDW JKC Registration 26-27

Student Information

Are you a returning student?

Full Name

Hebrew Name

Age

Birth Date

School

Grade Entering

Address

Home Phone

Child's Cell Phone

Child's Email

Name of Sibling 1

Age of Sibling 1

Name of Sibling 2

Age of Sibling 2

Father's Information

Father's Name

Father's Religion

Father's Occupation

Father's Business Name

Father's Address

Father's E-mail

Father's Cell

Father's Facebook

Mother's Information

Mother's Name

Mother's Religion

Mother's Occupation

Mother's Business Name

Mother's Address

Mother's Email

Mother's Cell

Mother's Facebook

Confidential

Is the mother of the child Jewish?

Yes

Is the father of the child Jewish?

Yes

Were there any conversions or adoptions in the family?

Yes

If yes, please describe:

Marital Status of Parents:

Married

Separated

Divorce

If divorced - how long?

Other

What makes your child shine? Any special interests, talents, or favorite activities?

What goals do you have for your child attending Jewish Kids Club?

Please share any other information you feel is important for Jewish Kids Club to be aware of. This can include exceptional behavior, concerns, particular activities, family relationships etc.

Comments

Emergency File

Please list below two emergency contacts

Emergency Contact 1

Relation to Child

Phone Number

Business Phone

Emergency Contact 2

Relation to Child

Phone Number

Business 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.

Doctor's Name

Doctor's Phone

Doctor's Address

Permission for Emergency Medical Treatment:*

As the parent(s) or legal guardian I/we authorize any adult acting on behalf of Jewish Kids Club to hospitalize or secure treatment for my child. I further agree to pay all charges for that care and/or treatment. It is understood that if time and circumstances reasonably permit, Jewish Kids Club personnel will try, but are not required, to communicate with me prior to such treatment.

I hereby give permission for my child to attend all field trips and outings sponsored by Jewish Kids Club.

Tuition Agreement

Yearly tuition rates:

$5,900 for 5 days a week ($590 monthly)

$5,500 for 4 days a week ($550 monthly)

$4,900 for 3 days a week ($490 monthly)

$4,100 for 2 days a week ($410 monthly)

$3,200 for 1 day a week ($320 monthly)

For all students who are NOT in PS100, there is a transportation fee: $90 monthly fee for once or twice a week, $160 monthly fee for 3-5 times a week.

Please select which days your child will be attending:*

Monday

Tuesday

Wednesday

Thursday

Friday

For questions, comments or discounted rates, contact us at jkcafterschool@gmail.com.

Payment options: (Please check off one.)

Pay by check on the first day of each month.

Pay by check on the first day of JKC with the entire year's tuition (to receive 5% off!)

Pay online now and we will charge the same card on the first day of every month. (You’ll be charged a small fee for credit card processing.)

How did you hear about us?

In order to complete your child's registration:

- submit full payment for (at least) September

- email updated health form to jkcafterschool@gmail.com

- wait for confirmation that your child is accepted

If you have any questions or concerns, feel free to contact us:

+1 (248) 943-7311

Commitment *

I understand that by submitting this form I am committing to pay the above outlined tuition fees.

Name

Initials

Date

Secure Online Payment

Credit Card Information

Number

Expiration

Code

Use contact info above

Name

Address

Zip

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