JUDA Hebrew School Registration Form 2022-2023
Child 1
*
First Name
Last Name
Birth Date
*
-
Month
-
Day
Year
Date
School and Grade Level 2022-2023 (School Name, Grade)
Gender
*
Male
Female
Do you have another child to register?
Yes
No
Child 2
First Name
Last Name
Birth Date
-
Month
-
Day
Year
Date
School and Grade Level 2022-2023, if applicable (School Name, Grade)
Gender
Male
Female
Do you have another child to register?
Yes
No
Child 3
First Name
Last Name
Birth Date
-
Month
-
Day
Year
Date
School and Grade Level 2022-2023 (School Name, Grade)
Gender
Male
Female
Child(ren)'s Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Parent/Guardian 1 Name
*
First Name
Last Name
Parent/Guardian 1 Phone Number
*
-
Area Code
Phone Number
Parent/Guardian 1 Email
*
example@example.com
Parent/Guardian 2 Name
*
First Name
Last Name
Parent/Guardian 2 Phone Number
*
-
Area Code
Phone Number
Parent/Guardian 2 Email
*
example@example.com
Is Parent/Guardian 1 Jewish?
*
Is Parent/Guardian 2 Jewish?
*
Are there any conversions in the family?
*
Does your child(ren) have any previous Jewish education? Does your child(ren) read/speak Hebrew?
OPTIONAL: Would you like your child to have a pizza dinner following JUDA? ($25 monthly per child)
Yes
No
Emergency Information
In case of emergency and we are unable to contact a parent, please write two individuals that can be contacted.
Emergency Contact 1
*
First Name
Last Name
Relationship to Child
*
Emergency Contact Phone Number
*
-
Area Code
Phone Number
Emergency Contact 2
*
First Name
Last Name
Relationship to Child
*
Emergency Contact Phone Number
*
-
Area Code
Phone Number
Name of child(ren)'s Primary Physician
*
Physician's phone number
*
-
Area Code
Phone Number
Is there anything we should know about any of your children (allergies, medical or learning conditions)?
Comments or Questions:
Informed Consent and Acknowledgment
*
As the parent(s) or legal guardian(s) of the child/ren note above, I/we authorize any adult acting on behalf of Chabad of Austin Inc/JUDA Hebrew School, to hospitalize or secure treatment for my child/ren. I further agree to pay for all charges for that care and/or treatment. It is understood that, if time and circumstances reasonably permit, the Hebrew School will try to communicate with me prior to such treatment. I/we hereby give permission for my child/ren to attend all field trips and outings sponsored by Chabad of Austin Inc/JUDA Hebrew School and be transported to and from the field trips and outings. I also allow my child to be photographed while participating in Hebrew School activities. I/we understand that these photographs may be used for publicity purposes.
Confirmation
*
By acknowledging and signing below, I am delivering an electronic signature that will have the same effect as an original manual paper signature. The electronic signature will be equally as binding as an original manual paper signature.
Signature
*
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Register now for JUDA Hebrew School
$
100.00
Please remit full payment ($899 per child) by September 1st, or set up payments. (Registration goes towards tuition). For scholarship options, please don't hesitate to contact us.
Choose the amount of children you're registering.
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