JewQ Registration Form 25-26

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 NameLast Name
Child is
Date of Birth

MonthDayYear
Date
Age
School attending currently
Current Class in School
Mother's Name

First NameLast Name
Father's Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

EirCode
Mother's Mobile Phone Number
Please enter a valid phone number.
Father's Mobile Phone Number
Please enter a valid phone number.
Mother's Email
example@example.com
Father's Email
example@example.com
How many chidren will you be registering?
Emergency Contact if we can't reach either parent in the case of an emergency

First NameLast Name
Emergency Contact Phone Number
Please enter a valid phone number.
Personal History
Is the child's father Jewish

YesNo
Is the child's mother Jewish

YesNo
Are there any conversions/adoptions in the family?

YesNo
If Yes, Please specify
Is your child on any medication that we should know about?

YesNo
If Yes, Please Specify
Does your child have any allergies?

YesNo
If Yes, Please Specify
I allow my childs photos to be used:

not at allIn internal communications only (eg parents of other children attending the programme)Chabad Emails/whatsappsany 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.

My Products

Annual Fee

€70.00 Quantity

I would like to pay via Bank transfer, please send me bank information

€ Free Quantity

My Child is already attending CKids Club on sundays. No charge.

€ Free Quantity

Total

€0.00

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

T-Shirt Size
Should be Empty:

JewQ Registration Form 25-26

Personal History

Payment