JUDA Registration Form

Primary Contact

First Name *

Last Name *

Phone Number *

Email *

Street Address *

City *

Postal Code *

State/Province *

Activity Subject

Secondary Contact

First Name *

Last Name *

Phone Number *

Email *

Share address

Same Address?

Street Address *

City *

Postal Code *

State/Province *

Relationship to Father Relationship Type(s)

How many kids do you want to apply for? *

Child 1

First Name *

Last Name *

Gender *

Birth Date *

Month

Day

Year

Child is registering to: *

JUDA 2025-2026 Fall Semester

JUDA 2025-2026 Semester 2

Additional Information

Does your child have an IEP?

Grade

Please tell us one or two of your child’s special interests or character traits

Medical History

Does the child have a chronic illness? *

Yes

receiving medication on a regular basis? *

Yes

Does the child have allergies? *

Yes

Allergy details *

Please list any information that may directly affect the safe care or medical treatment of your child

Participant Fee $

Child 2

First Name *

Last Name *

Gender *

Birth Date *

Month

Day

Year

Child is registering to: *

JUDA 2025-2026 Fall Semester

JUDA 2025-2026 Semester 2

Additional Information

Does your child have an IEP?

Grade

Please tell us one or two of your child’s special interests or character traits

Medical History

Does the child have a chronic illness? *

Yes

receiving medication on a regular basis? *

Yes

Does the child have allergies? *

Yes

Allergy details *

Please list any information that may directly affect the safe care or medical treatment of your child

Participant Fee $

Child 3

First Name *

Last Name *

Gender *

Birth Date *

Month

Day

Year

Child is registering to: *

JUDA 2025-2026 Fall Semester

JUDA 2025-2026 Semester 2

Additional Information

Does your child have an IEP?

Grade

Please tell us one or two of your child’s special interests or character traits

Medical History

Does the child have a chronic illness? *

Yes

receiving medication on a regular basis? *

Yes

Does the child have allergies? *

Yes

Allergy details *

Please list any information that may directly affect the safe care or medical treatment of your child

Participant Fee $

Child 4

First Name *

Last Name *

Gender *

Birth Date *

Month

Day

Year

Child is registering to: *

JUDA 2025-2026 Fall Semester

JUDA 2025-2026 Semester 2

Additional Information

Does your child have an IEP?

Grade

Please tell us one or two of your child’s special interests or character traits

Medical History

Does the child have a chronic illness? *

Yes

receiving medication on a regular basis? *

Yes

Does the child have allergies? *

Yes

Allergy details *

Please list any information that may directly affect the safe care or medical treatment of your child

Participant Fee $

Emergency Contact

First Name *

Last Name *

Phone Number *

Relationship to the kids

Photo release authorization *

I hereby consent to allow the school to utilize photos and videos featuring my child/ren in promotional and marketing materials on our website, ads, and social media platforms. These captivating visuals will showcase the vibrant educational environment and the exciting activities taking place at our school, while also safeguarding the privacy and security of each student. Your support in sharing the joyous moments of their educational journey would greatly contribute to fostering a positive and engaging community.

Yes

Tuition Payment Options *

In full

5 monthly payments

Discount code

Discount Amount $

Interval of Installments

JUDA Registration Form

Chabad Center for Jewish Life & Learning