Jewish Kids Club - Chabad of the Medical Area, Serving UMass and Shrewsbury

The program will run from Nov 9- May 17th.
There will be no club on long weekends/public holidays. Parents are welcome to stay for the program or to drop off their child if he/she is toilet trained.
Student Information
Student Name:*
First Name Last Name

Address*

Hebrew Name(if student has):
Birth Date*

Month Day Year
Age*
School/Daycare:
Parent Information
Mother's Name:*
Phone Number*
E-mail*
Father's Name:*
Phone Number*
E-mail*
Emergency Information
Does your child have any allergies or medical conditions we should be aware of? Please explain.
Emergency Contact
Phone Number
As the parent(s) or legal guardian of the above child, I/we authorize any adult acting on behalf of Jewish Kids Club to hospitalize or secure treatment for my child. I further agree to pay all charges for that care and/or treatment. It is understood that if time and circumstances reasonably permit, Jewish Kids Club personnel will try, but are not required, to communicate with me prior to such treatment.
YES
Parental Consent
I allow my child to be photographed while participating in Jewish Kids Club activities and understand that these pictures may be used for marketing purposes.

YES NO
Tuition Payment Options:*

Tuition charged monthly, November- May ($60)Pay full tuition today ($420)Children of UMass students ($0)Private tutoring (all ages)- $50 per lesson
Total

$0.00

Payment

Credit Card

We accept Visa, MasterCard, American Express, Discover
Credit Card Number	Security Code
Name on Card
Expiration Month	Expiration Year

Billing Address

Street Address

City

State / Province

Postal / Zip Code

Country

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The program will run from Nov 9- May 17th.