Registration

Student Information
Full Name*

First Name Last Name
Was this student enrolled in JUDA for the 23-24 session?*

YesNo
Birth Date*

Month Day Year
Grade Entering*
Check as many or as few apply.

My child can read basic Hebrew.My child has had some previous Jewish education.
Please describe any allergies to food or medicines:
Please describe any special medical or behavioral information that we should be made aware of:
Additional Student
Do you have another child to enroll?*

YesNo
Full Name*

First Name Last Name
Was this student enrolled in JUDA for the 23-24 session?*

YesNo
Birth Date*

Month Day Year
Grade Entering*
Check as many or as few apply.

My child can read basic Hebrew.My child has had some previous Jewish education.
Please describe any allergies to food or medicines:
Please describe any special medical or behavioral information that we should be made aware of:
Parent's Information
Mother
Name*

First Name Last Name
E-mail
Cell Phone*
*

Born JewishConverted to JudaismNot Jewish
Check here if there were any adoptions or conversions in the mother's family.
Details
Father
Full Name*

First Name Last Name
E-mail
Cell Phone*
*

Born JewishConverted to JudaismNot Jewish
Check here if there were any adoptions or conversions in the father's family.
Details
Household

Address*

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

Family E-mail* Best Email for Correspondence
Emergency Contact
First Contact
Full Name

First Name Last Name
Phone Number
Relation to Student
Second Contact
Full Name

First Name Last Name
Phone Number
Relation to Student
Authorizations
I hereby give permission for my child(ren) to be transported to and from field trips and to participate in them in all JUDA activities. I understand that during the course of JUDA my child(ren) can be hurt. I accept the risk of possible injury and authorize any member of the JUDA staff to render any necessary first aid. Furthermore, in an emergency case, I hereby authorize Chabad Jewish Community Center of Riverside personnel to have my child(ren) taken care of by a physician or other medical person in any way the situation calls for.
Select One:*

AgreeDecline
I give permission to JUDA, and those authorized by JUDA, to take photographs and to make recordings of my children and my family, and to use them in original or modified form in all media now or hereafter known, with or without my name or information about me, for the promotion, public education, and/or fundraising activities of JUDA or Chabad Jewish Community Center of Riverside.
Select One:*

AgreeDecline
Tuition
Full tuition: $550
Register by August 30th: $500

Includes registration fee, books and all supplies.

Discounts:
5% discount off for each additional child of the same family.
5% additional discount off your total tuition for each child of another family you successfully introduce to JUDA
Choose One:*

Full Tuition $500.00Subsidized Tuition $375.00
Choose One:* Sibling Discount Applied

Full Tuition $975.00Subsidized Tuition $731.25
Donation

I want to support a child needing tuition assistance, gifting them this special experience.
$100$180$375$500
Payment
Today's Payment:

$0.00

I would like to pay today:Full amount$0.00 minimum$
For the remaining balance after today, charge my card equal monthly payments over: Monthly payments will start 30 days from today.

Payment*

Credit Card Paypal

Postal / Zip Code

Country

Please note: Your child is not registered in JUDA until you receive an acceptance confirmation phone call or email.
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Educate Your Child... Educate a Generation

Student Information

Additional Student

Parent's Information

Emergency Contact

Authorizations

Tuition

Donation

Payment

Please note: Your child is not registered in JUDA until you receive an acceptance confirmation phone call or email.