Register 5780

Child's Info
Child's Name
First NameLast Name
Hebrew NameIf available
Birth Date
MonthDayYear
Grade Entering
School Attending
Previous Jewish Education?
Any special learning, behavioral needs or any family or living issues?
Additional Comments
Parent's Info
Father's Name
First NameLast Name
Hebrew NameIf available
Home
Area CodePhone Number
Cell
Area CodePhone Number
Click to edit
Do you have Whatsapp Messenger Service?
E-mail
Mother's Name
First NameLast Name
Hebrew NameIf available
Home
Area CodePhone Number
Cell
Area CodePhone Number
Do you have Whatsapp Messenger Service?
E-mail

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Did someone refer you?How did you find out about our program?
Emergency Information & Terms
In the rare case that there is an emergency and we cannot reach either parent, please let us know who we can contact.
Emergency Contact 1
First NameLast Name
Home
Area CodePhone Number
Cell
Area CodePhone Number
Emergency Contact 2
First NameLast Name
Home
Area CodePhone Number
Cell
Area CodePhone Number
Doctor's Name
First NameLast Name
Doctor's Number
Area CodePhone Number
Allergies or other Medical Condition
What is your preference for reminder messageing?
Click to edit
Agreement
As parent(s) or legal guardian, I/we authorize all medical transportation, medical and surgical treatment, X-ray, laboratory, anesthesia, and other medical and/or hospital procedures which may be performed or prescribed by the attending physician and/or paramedics for my child and waive my right to informed consent of treatment. I further agree to pay all charges for that care and/or treatment. This waiver applies only in the event that neither parent/guardian can be reached in the case of an emergency.
I allow my child to be photographed and for the photos to be used in print, video and digital media.
I hereby give permission for my child to attend all field trips and outings sponsored by CKids GROW Club
Agreement*
I have read the terms and conditions as laid out above and accept.
Amount to Charge
Choose Payment Option
Entire Year RegistrationEntire Year Registration Early Bird by Sept 30$150 mandatory Deposit - secures the early rate price3 Installments each with the early bird deposit3 Installments each without the early bird deposit2nd sibling Entire Year Registration2nd Sibling Entire Year Early Bird
Total $ USD
$0.00

Payment

Credit Card Check

Postal / Zip Code

Country

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Child's Info

Parent's Info

Emergency Information & Terms

Agreement

Amount to Charge