JewQ Registration Form 25-26
Join JewQ Club Ireland. Lessons run on Zoom once weekly - will confirm an exact time and date to suit participants.
Name of Child
First Name
Last Name
Child is
Please Select
Male
Female
Date of Birth
-
Month
-
Day
Year
Date
Age
School attending currently
Current Class in School
Mother's Name
First Name
Last Name
Father's Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
EirCode
Mother's Mobile Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Father's Mobile Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Mother's Email
example@example.com
Father's Email
example@example.com
How many chidren will you be registering?
Please Select
1
2
3
4
5
Emergency Contact if we can't reach either parent in the case of an emergency
First Name
Last Name
Emergency Contact Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Personal History
Is the child's father Jewish
Yes
No
Is the child's mother Jewish
Yes
No
Are there any conversions/adoptions in the family?
Yes
No
If Yes, Please specify
Is your child on any medication that we should know about?
Yes
No
If Yes, Please Specify
Does your child have any allergies?
Yes
No
If Yes, Please Specify
I allow my childs photos to be used:
not at all
In internal communications only (eg parents of other children attending the programme)
Chabad Emails/whatsapps
any social media, flyers or emails
Anything else you think we should know
Payment
Price per year is €70 including the book. There may be additional costs for trips and activities. FREE for children who already attend Chabad Kids Club.
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Annual Fee
€70.00
€
70.00
Quantity
1
2
3
4
5
6
7
8
9
10
I would like to pay via Bank transfer, please send me bank information
Free
€
Free
Quantity
1
2
3
4
5
6
7
8
9
10
My Child is already attending CKids Club on sundays. No charge.
Free
€
Free
Quantity
1
2
3
4
5
6
7
8
9
10
Debit or Credit Card
First Name
Last Name
Credit Card Number
Security Code
Expiration Month
January
February
March
April
May
June
July
August
September
October
November
December
Expiration Month
Expiration Year
2026
2027
2028
2029
2030
2031
2032
2033
2034
2035
2036
2037
2038
2039
2040
2041
2042
2043
2044
2045
Expiration Year
T-Shirt Size
Please Select
Child Small
Child Medium
Child Large
Child X-Large
Adult Small
Adult Medium
Adult Large
Submit
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