JUDA ENRICHMENT REGISTRATION

JUDA Enrichment Registration Form
Expected Start Date

Month Day Year
Student Information
Name *

First Name Last Name
Gender *

Female Male
Birth Date *

Month Day Year
Additional Child

First Name Last Name
Gender

Female Male
Birth Date

Month Day Year
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
List any serious illnesses or medical information your child has that we should know.
Is your child on an IEP in school? Explain.
Does your child have any allergies? (If yes, head over to JewishSD.org/allergy to submit a care plan.)

Yes No
Doctors Name *

First Name Last Name
Doctors Phone Number *

Area Code Phone Number
Parent/Guardian Information 1
Full Name *

First Name Last Name
Best Phone *

Area Code Phone Number
E-mail *
Parent/Guardian Information 2
Full Name

First Name Last Name
Best Phone

Area Code Phone Number
E-mail
Address - Same As Childs

Yes No
If your address is different than the childs please fill out the info below. Otherwise move onto the next section.
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Tuition:

Tuition is set up on a sliding scale where every family can opt for what they are able to contribute towards their child's Jewish education.

Advance yearly tuition: $225 per child (appx $15 per session) (5% sibling discount for each sibling)

Pay per session: $25 per week per child

Juda Enrichment Partner: $450

Yearly tuition of any level can be divided into two payments and can be paid via check or credit card.

Scholarships are available upon request.
Emergency Infomation
In the event of an emergency, I give permission to Chabad Jewish Center of South Dakota to transport my child/ren to the nearest hospital. I give my consent for emergency medical treatment to be used if necessary.
Type name/s of child/children here
Signature

Clear
Today's Date

Month Day Year
Date
Emergency Contact - Other than Parent/Guardian
Full Name *

First Name Last Name
Relationship to child *
Phone *

Area Code Phone Number
Should be Empty:

JUDA Enrichment Registration Form

Student Information

Parent/Guardian Information 1

Parent/Guardian Information 2

Emergency Infomation

Emergency Contact - Other than Parent/Guardian