JKG Sample Day Registration Form

JKG Sample Day Registration Form

Want to find out if JKG is right for your family? Try out JKG Afternoon Community, B Mitzvah, or Teen Leadership Academy programs for a sample day!
Child 1 Information
Child #1 First and Last Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Current Grade*
Current School*
Allergies, Medications, and/or Dietary Restrictions
If your child has any allergies, please list them here and include severity, symptoms, and treatment. If they have important medical information or dietary restrictions, please list that here as well.
Which program would your child like to try out?*
Which date would your child like to join us for a sample day? *
If you have multiple dates that work for you, please enter them above. We will do our best to accommodate your preferences.
Will your child need JKG transportation on their sample day?

Yes, I need JKG transportationNo, I don't need JKG transportationI'm not sure yet
If you selected “Yes, I need JKG transportation,” does your child require any of the following transportation needs when riding in a JKG vehicle? (Note that all students under the age of 8 are required by law to be in a booster seat or car seat.)

Booster Seat (JKG will provide)Car Seat (I will provide in advance of sample day)My child does not need a car seat or a booster seat and is at least 8 years old
Child 2 Information
Child #2 First and Last Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Current Grade
Current School
Allergies, Medications, and/or Dietary Restrictions
If your child has any allergies, please list them here and include severity, symptoms, and treatment. If they have important medical information or dietary restrictions, please list that here as well.
Which program would your child like to try?
Which date would your child like to join us for a sample day?
Will your child need JKG transportation on their sample day?

Yes, I need JKG transportationNo, I don't need JKG transportationI'm not sure yet
If you selected “Yes, I need JKG transportation,” does your child require any of the following transportation needs when riding in a JKG vehicle? (Note that all students under the age of 8 are required by law to be in a booster seat or car seat.)

Booster Seat (JKG will provide)Car Seat (I will provide in advance of a sample day)My child does not need a car seat or a booster seat and is at least 8 years old
Primary Parent/Guardian

Primary parent or guardian contact details.
First and Last Name*

First NameLast Name
Email address*
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Secondary Parent/Guardian (if applicable)

Secondary parent or guardian contact details.
First and Last Name

First NameLast Name
Email address
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact Information

Please add the information below for at least one emergency contact (other than parents/guardians) who can be reached in case of an emergency.
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
Relationship to the Child*
Authorized Pick-Up

If someone other than the parent/guardian or emergency contact person will pick up your child(ren) from their sample day, please provide their details below.
Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Relationship to the Child
Should be Empty:

JKG Sample Day Registration Form

Child 1 Information

Child 2 Information

Primary Parent/Guardian

Secondary Parent/Guardian (if applicable)

Emergency Contact Information

Authorized Pick-Up