Student Information
Are you a returning student?
- Please Select -
Yes
No
Full Name
Hebrew Name
Age
Birth Date
School
Grade Entering
- Please Select -
Pre-K
Kindergarten
First
Second
Third
Fourth
Fifth
Sixth
Seventh
Eight
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
No
Is the father of the child Jewish?
Yes
No
Were there any conversions or adoptions in the family?
Yes
No
If yes, please describe:
Marital Status of Parents:
Married
Separated
Divorce
If divorced - how long?
Other
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:
$5,400 for 5 days a week ($540 monthly)
$5,000 for 4 days a week ($500 monthly)
$4,500 for 3 days a week ($450 monthly)
$3,600 for 2 days a week ($360 monthly)
$2,700 for 1 day a week ($270 monthly)
For all students who are NOT in PS100, there is a transportation fee: $40 monthly fee for once or twice a week, $75 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 (332) 239-9892
Commitment *
I understand that by submitting this form I am committing to pay the above outlined tuition fees.
Name
Initials
Date
Secure Online Payment
Amount to charge my card today
Credit Card Information
Type
Visa
MC
Amex
Discover
Number
Expiration
Code
Use contact info above
Name
Address
Zip
Total Amount
0.00
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