Club Ed 2021-2022 Application

Club Ed 2021-2022 Application
If you prefer to manually fill out this application and email it to Club Ed, please download the application here.
Student Information
Name *

First Name Last Name
Middle Initial
Birth Date *

Month Day Year
Gender *
Ethnicity
School Attending *
Grade in 2021-2022 *
Student Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Does your child receive any of the following services (check any that apply)

Special Needs Special Education Free/Reduced Lunch
Primary Parent/Guardian Information
Primary Parent/Guardian Enrolling the Child *

First Name Last Name
Relationship to Student *
Email Address *
Primary Phone Number *
Please enter a valid phone number.
Secondary Phone Number
Please enter a valid phone number.
Secondary Parent/Guardian Information
Name

First Name Last Name
Relationship to Student
Email
example@example.com
Primary Phone Number
Please enter a valid phone number.
Secondary Phone Number
Please enter a valid phone number.

Registration Payment

A non refundable registration fee ($50 per child), first month's tuition, and last month's deposit are all due at the time of registration. By entering your account information below, your account will NOT be charged when you click "Submit". Payment will be processed after your information is entered into our system. This may take a few days.
Click your School District for Payment Information

Fort Lee Edgewater North Bergen Fairview Palisade Park
Initial Payment- please enter dollar amounts- registration fee, first month tuition, and last month deposit required *
For Fort Lee and Edgewater Families ONLY

Check this box if you would like to register for the 7pm Extra Hour (additional $80 per month)
How would you like to make your registration payment? *
Upload your Approved Office for Children or Urban League Agreement *

Cancel of
Checking Account (ACH) Bank Name: *
Routing Number *
Account Number *
Authorized Signature *

Clear
Card Holder Name *

First Name Last Name
Credit Card Number: *
Please place 4 digits of your credit/debit card in each box.

For American Express Cards, please disregard the 4th box.
First 4 digits *
Second 4 digits *
Third 4 digits *
Fourth 4 digits
Expiration Date: *
Authorized Signature: *

Clear
Please indicate if you would like your credit card or ACH automatically charged each month: *

Yes No
By choosing YES, you authorize JFCS to charge your credit card or checking account monthly.

By choosing NO, you will have monthly invoices emailed to you for online payment.

Policies and Procedures Acknowledgement
Media Consent (Please pick one): *

I give permission for my child to be photographed or otherwise recorded during after-school events and activities, and for any and all such photographs to be displayed by Jewish Family & Children's Services of Northern New Jersey, Inc. in any medium (books, newsletters, web sites, etc.), whether now or hereafter known or developed. I DO NOT give permission for my child to be photographed or otherwise recorded during afterschool events and activities.
*

I give my child permission to participate in Club Ed Afterschool Program for the 2021-2022 school year. I understand that this consent will be in effect as of the date of my signing this form and will continue as long as my child is enrolled in the afterschool program. By my signature below, I confirm I have received, understand and agree to abide by all policies and procedures regarding my child's enrollment in the Club Ed Afterschool Program. I have read the Club Ed Parents/Guardians Manual.
Click here to view the Club Ed Parents/Guardians Manual
By signing below, I agree I have received and understand the following information which is stated in the Club Ed Parents/Guardians Manual:
1. General Program Information
2. Department of Children and Families, OOL, Information to Parents Acknowledgement
3. Release of Children
4. Student Behavior Guidelines
5. Discipline Guidelines
6. Expulsion Guidelines
7. Management of Communicable Diseases
8. Phot/Video/Interview Disclosure
9. Screen.TV/Video Guidelines
10. Social Media/Technology
11. Methods used to communicate to parentss
12. Medication Administration
13. Waiver of Liability Related to Coonavirus/COVID-19 Assumption of the Risks
14. Tuition and Fees
Signature *
Please upload any documents such as an allergy action plan here.

Cancel of
Office Use ONLY- Do not check this box

Finance
Office Use ONLY-Start Date
Should be Empty:

Club Ed 2021-2022 Application

Registration Payment