Registration Form - Jewish Kids Club - Chabad of Milford

Home Address*

Have there been any conversions in your family (including parents/grandparents)?*
YesNo
Email address for all communication:*
STUDENT INFORMATION
Student's Name*
Hebrew Name
Date of Birth*
MonthDayYear
To calculate Hebrew birthday, please enter approx. time of birth
HourMinutes
School attending, Grade (Fall '21)*
Summarize your child's previous Jewish education/knowledge*
Please list any health problems, medications, or health information we need to know:
Emergency Contact*
First NameLast Name
Phone Number*
Area CodePhone Number
PAYMENT INFORMATION
Choose Plan 1 or Plan 2*
Plan 1: One Payment of $425 for the yearPlan 2: Two payments: $250 at sign-up, remainder to be charged Jan. 9

Payment*

Credit Card

Billing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

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Registration Form - Jewish Kids Club