Ckids Registration

Child's Information
Child's Full Name*

First Name Last Name Hebrew Name
Birth Date*

Month Day Year
Gender*

MaleFemale
Grade entering (2024-25)*
Home Phone*

Area Code Phone Number

Home Address*

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

Is the natural mother of the child Jewish?*

YesNo
Were there any conversions or adoptions in the child's family?*

YesNo
If you answered yes to previous question please explain.
Has your child had any previous Jewish Education?*

YesNo
If you answered yes to previous question please explain where and for how long
Parent Information
Parent's relationship*

MarriedDivorcedSeparatedWidowed
Father's Name*

First Name Last Name Hebrew Name
Father's Birth Date*

Month Day Year
Father's E-mail
Father's cell

Area Code Phone Number
Father's Occupation
Mother's Name*

First Name Last Name Hebrew Name
Mother's Birth Date*

Month Day Year
Mother's E-mail*
Mother's cell*

Area Code Phone Number
Mother's Occupation
Medical Information
Person to be contacted in case of an emergency when parents cannot be reached.
Full Name*

First Name Last Name
Phone Number*

Area Code Phone Number
Relationship to child*
Name of Physician*
Physician's Phone Number*

Area Code Phone Number
Confidential: Does child have any learning or physical disabilities/health challenges.*

YesNo
If Yes please explain
Allergies
In case of an emergency, I (we) authorize the school to take whatever medical measures they deem necessary for my child in the event of a medical emergency. If a parent or emergency contact cannot be reached, the family physician will be contacted.
Consent:*

I herby give consent for my child to participate in all activities at Chabad OT unless I advise you otherwise in writing.Permission is hereby given to use digital, photographic and video images or audio in promoting Ckids and in other venutres directly relating to Chabad of Old Tappan.I further agree to indemnify and hold harmless Chabad of Old Tappan and its officers, servents or assigns from any liability concerning our child's involvement in Ckids activities.
Tuition
Tuition Price*
Donate to the Scholarship Fund for families in need.

$36$100$360$540$1000
Tuition Agreement*

We agree to pay the full tuition.We are requesting a scholarship.We are requesting a sibling discount of 10%
Payment Options*

Please charge my credit card in full today.Please use my echeck for the full tuition amount.Please charge my card in ten equal credit card payments starting today and on 1st of each subsequent month.Please process my echeck payments in ten equal payments starting today and on 1st of each subsequent month.
If requesting a scholarship or sibling discount we will contact you to confirm the final amount before charging your card or processing your echeck.

Payment

Credit Card eCheck

Postal / Zip Code

Country

Should be Empty:

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Child's Information

Parent Information

Medical Information

Tuition