Have you ever registered your child(ren) for CKids Hebrew School before?* YesNo Parent's Info Mother's Name* First Name Last Name Hebrew Name If available Home Area Code Phone Number Cell* Area Code Phone Number Do you have Whatsapp Messenger Service? E-mail* Father's Name First Name Last Name Hebrew Name If available Home Area Code Phone Number Cell Area Code Phone Number Do you have Whatsapp Messenger Service? E-mail Address Street Address Street Address Line 2 City State / Province Postal / Zip CodePlease SelectUnited StatesAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanThe BahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChilePeople's Republic of ChinaRepublic of ChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCook IslandsCosta RicaCote d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonThe GambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern MarianaNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint BarthelemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSomalilandSouth AfricaSouth OssetiaSpainSri LankaSudanSurinameSvalbardSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTristan da CunhaTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamBritish Virgin IslandsUS Virgin IslandsWallis and FutunaWestern SaharaYemenZambiaZimbabweOther Country Are the natural father, mother and maternal grandmother of the child Jewish?* YesNo Have there been any conversions or adoptions in the family?* YesNo Did someone refer you? How did you find out about our program? Child's Info For how many child/children 1 Child's Name* First Name Last Name 1 Hebrew Name If available 1 Birth Date* 1 - January2 - February3 - March4 - April5 - May6 - June7 - July8 - August9 - September10 - October11 - November12 - December Month12345678910111213141516171819202122232425262728293031 Day202020192018201720162015201420132012201120102009200820072006200520042003200220012000 Year 1 Any special learning, behavioral needs or any family or living issues? 1 Additional Comments 2 Child's Name* First Name Last Name 2 Hebrew Name If available 2 Birth Date* 1 - January2 - February3 - March4 - April5 - May6 - June7 - July8 - August9 - September10 - October11 - November12 - December Month12345678910111213141516171819202122232425262728293031 Day202020192018201720162015201420132012201120102009200820072006200520042003200220012000 Year 2 Any special learning, behavioral needs or any family or living issues? 2 Additional Comments 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 Name Last Name Home Area Code Phone Number Cell Area Code Phone Number Emergency Contact 2 First Name Last Name Home Area Code Phone Number Cell Area Code Phone Number Doctor's Name First Name Last Name Doctor's Number Area Code Phone Number Allergies or other Medical Condition Pick-up Authorization List name(s) of those, other than parents, who are authorized to pick up your child(ren) from school:* Agreement As parent(s) or legal guardian of the above child, I/we authorize any adult acting on behalf of CKids After School/Chabad of Rancho Mirage to hospitalize or secure treatment for my child. This includes 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 After School. Agreement* I have read the terms and conditions as laid out above and accept. Registration - $25 Is your child(ren) an existing CKids Member?* YesNo Are you only registering for the Try-out?* YesNo (Ckids member) Please Select Desired Program* 4-Day Program (Mon-Thurs) - $160/month1 Day per Week - $60/month2 Days per Week - $100/month3 Days per Week - $140/month (Ckids member) 2 Please Select Desired Program* 4 Day Program (Mon-Thurs) - $152/month1 Day per Week - $57/month2 Days per Week - $95/month3 Days per Week - $133/month Please Select Desired Program* 4 Day Program (Mon-Thurs) - $240/month1 Day per Week - $80/month2 Days per Week - $144/month3 Days per Week - $200/month Please Select Desired Program* 4 Day Program (Mon-Thurs) - $240/month1 Day per Week - $80/month2 Days per Week - $144/month3 Days per Week - $200/month 2 Please Select Desired Program* 4 Day Program (Mon-Thurs) - $228/month1 Day per Week - $76/month2 Days per Week - $136.8/month3 Days per Week - $190/month 2 Please Select Desired Program* 4 Day Program (Mon-Thurs) - $228/month1 Day per Week - $76/month2 Days per Week - $136.8/month3 Days per Week - $190/month Please Choose the Day(s)* MondayTuesdayWednesdayThursday Please Choose the Month(s)* JanuaryFebruaryMarchAprilMayJune Weekly Try-Out Option (one-time only): Note: Try-out reservations must be booked by the Wednesday before the selected week. Choose a Program to Try 4-Day Program (Mon-Thurs) - $401 Day Program - $152 Day Program - $253 Day Program - $35 Choose a Program to Try 4-Day Program (Mon-Thurs) - $601 Day Program - $202 Day Program - $363 Day Program - $50 Please Choose the Day(s)* MondayTuesdayWednesdayThursday Select the Week You Want to Attend:* Month Day Year Special December Try-Out + Open House (December 8–11) Note: Open House on December 10 has no cost Choose Try-Out Program to Attend Open House (December 10)3 Day Program (Mon-Tue & Thurs) - $352 Day Program - $251 Day Program - $15 Please Select Desire Day(s) Monday, December 8Tuesday, December 9Thursday, December 11 Payment $25 One-Time Registration Fee Please note that full program registrations (excluding try-outs) will receive an invoice sent to their email address. Total $ USD $25.00 Payment Credit Card Check Credit Card We accept Visa, MasterCard, American Express, Discover Credit Card Number Security Code Name on Card1 - January2 - February3 - March4 - April5 - May6 - June7 - July8 - August9 - September10 - October11 - November12 - December Expiration Month2025202620272028202920302031203220332034 Expiration YearCheck can be made payable and mailed to Chabad of Rancho Mirage • 72-295 Via Marta • Rancho Mirage, CA 92270Billing Address Street Address City State / Province Postal / Zip CodePlease SelectUnited StatesAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanThe BahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChilePeople's Republic of ChinaRepublic of ChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCook IslandsCosta RicaCote d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonThe GambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern MarianaNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint BarthelemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSomalilandSouth AfricaSouth OssetiaSpainSri LankaSudanSurinameSvalbardSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTristan da CunhaTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamBritish Virgin IslandsUS Virgin IslandsWallis and FutunaWestern SaharaYemenZambiaZimbabweOther Country Submit Clear Form Should be Empty: This page uses TLS encryption to keep your data secure.
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