Park Ridge Jewish Discovery Program

PARK RIDGE JEWISH DISCOVERY PROGRAM REGISTRATION FORM
Please fill out one form per child. For new students, we will reach out to you to set up a quick phone call interview so that we can best cater our program to suit your child's needs. Registration will be confirmed once the interview takes place.

If you have any questions feel free to contact our director Morah Rivky Hershkovich by emailing Rivky@ChabadCaresToday.com

EARLY BIRD DISCOUNT: SIGNUP BEFORE SEPTEMBER 1ST FOR 10% OFF!

We look forward to a productive and special session with your child!
Child's Information
Child's Name*

First NameLast Name
Birth Date*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Current School*
Grade*
Child's Favorite Activity
Does your child have any special abilities, behaviors or habits you want us to be aware of?
What would you like your child to gain by joining Park Ridge Jewish Discovery Program?
YesNoOther
Please explain:*
YesNo
If yes please explain:*
Parent Information
Mother's Name*

First NameLast Name
Mother's Cell *
Please enter a valid phone number.Format: (000) 000-0000.
Father's Name*

First NameLast Name
Father's Cell *
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Relationship*
Confidential: Does your child(ren) have any allergies or other medical condition we should be aware of?
I agree that in the event of an emergency, Park Ridge Jewish Discover Program has my permission to arrange for any necessary first-aid or care by a licensed physician/first-aid worker. Park Ridge Jewish Discovery Program has my permission to use my child's photo in its publicity materials. I have completed the Enrollment Form and agree to pay any balance according to the terms of agreement outlined.
Cost $450 Per Child

10% off per additional child. Cost includes supplies & snack fee. No one will be turned away due to lack of funds. Scholarships and payment plans are available, please email info@chabadcarestoday.com for more info. To pay by credit card, use the form below. You can also pay via Zelle at info@chabadcarestoday.com or Venmo @Chabad-Cares.
Email*
example@example.com

Amount*

USD

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Should be Empty:

PARK RIDGE JEWISH DISCOVERY PROGRAM REGISTRATION FORM

Child's Information

Parent Information

Emergency Contact

Cost $450 Per Child