Yaldeinu Application 2026
Welcome! To register, please sign up for each child and you will get an email/call once approved. Please note that space is limited. Thank you!
Student's Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Address of Parent/Guardian:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
School Attending (Mention if Public, Homeschool, or Yeshiva if not clear by the name)
*
Grade
Home Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Father's Full Name
*
First Name
Last Name
Father's Cell Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Mother's Full Name
*
First Name
Last Name
Mother's Cell Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Name of Emergency Contact
*
First Name
Last Name
Relationship to Student
*
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
By providing phone number/contact information, you consent to receiving weekly SMS text messages as well as on a WhatsApp group that include reminders/updates about the program.
*
*
By providing phone number/contact information, you consent to receiving weekly SMS text messages as well as on a WhatsApp group that include reminders/updates about the program.
Is your child a male/female?
*
Please Select
Male
Female
Which program are you interested in?
*
Dance Classes For Girls (12-1 PM)
Martial Arts Classes For Boys (12-1 PM)
Martial Arts Classes for Boys (1-2 PM)
Art Class (1-2 PM)
Baking Class (2-3PM)
NEW: Basketball Class (2-3PM)
NEW: Basketball Class (3-4PM)
NEW: Jewelry Class (3-4PM)
Chess Class (3-4 PM)
Date when student will begin attending Classes
*
-
Month
-
Day
Year
Date
Does your child have any allergies?
*
Please Select
Yes
No
If yes, please specify:
How did you find out about the program?
*
Please Select
Facebook
Instagram
WhatsApp
Newsletters/Newspapers
Flyer
Parent Referral
If a parent from our program referred you, please put in their name. If no one referred you from our program, please put N/A in both boxes:
*
First Name
Last Name
Media Consent
Consent to photograph, film, or videotape a student for non-profit use (e.g. educational, public service, or health awareness purposes).
Student's Full Name
*
First Name
Last Name
I hereby consent to the participation in interviews, the use of quotes, and the taking of photographs, movies or video tapes of the student named above by parent/guardian. I also grant Chazaq Organization USA the right to edit, use, and reuse said products for non-profit purposes including use in print, on the internet, and all other forms of media. I also hereby release Chazaq Organization USA and its agents and employees from all claims, demands, and liabilities whatsoever in connection with the above. Signature of Parent/Guardian:
*
*
I hereby consent to the participation in interviews, the use of quotes, and the taking of photographs, movies or video tapes of the student named above by parent/guardian. I also grant Chazaq Organization USA the right to edit, use, and reuse said products for non-profit purposes including use in print, on the internet, and all other forms of media. I also hereby release Chazaq Organization USA and its agents and employees from all claims, demands, and liabilities whatsoever in connection with the above. Signature of Parent/Guardian:
Date
*
-
Month
-
Day
Year
Date
I hereby release Chazaq Organization USA of any medical, psychological, health, and injury related issues and/or damage, and expenses related to such incidents. Signature of Parent/Guardian:
*
*
I hereby release Chazaq Organization USA of any medical, psychological, health, and injury related issues and/or damage, and expenses related to such incidents. Signature of Parent/Guardian:
Date:
*
-
Month
-
Day
Year
Date
Submit
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