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JUDA Registration 2023

Student Information
Full Name*

First Name Last Name
Hebrew Name
Birth Date*

Month Day Year
Approximate time of birth*

DaytimeNightime
School Attending*
Grade Entering*
Does your child have any allergies that we should be aware of? *

YesNo
Previous Jewish Education
Second Child
Full Name

First Name Last Name
Hebrew Name
Birth Date

Month Day Year
Approximate time of birth

DaytimeNightime
School Attending
Grade Entering
Previous Jewish Education
Additional Information: Please let us know if there are any allergies or other important information we need to be aware of.*
Parents Information
Father's name*

First Name Last Name
Father's E-mail*
Father's Cell*

Area Code Phone Number
Mother's Name*

First Name Last Name
Mother's E-mail*
Mother's Cell*

Area Code Phone Number
Is the child's mother Jewish? *

YesNo
Are there any conversions in the family?*

YesNo
Are there any adoptions in the family?*

YesNo
Is your family affiliated with a congregation? If yes, which one?*

NoYes
The congregation we belong to:
Authorized Pickup and Emergency Contacts
Authorized Pickup*

First Name Last Name
Cel Number*

Area Code Phone Number
Emergency Contact*

First Name Last Name
Cel Number*

Area Code Phone Number
I hereby give permission for my child to be transported to and from field trips, and to participate in all JUDA activities. I understand that during the course of JUDA my child can be hurt. I accept the risk of possible injury and authorize any member of the Chabad Pod staff to render any necessary first aid. Furthermore, in an emergency case, I hereby authorize Chana Kugel, Rabbi Zevi Kugel or another staff member to have my child taken care of by a doctor or other medical person in any way the situation calls for.
Permission Signature*
I give permission to Chabad Pod, and those authorized by Chabad Pod, 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 Chabad Pod.
Media Signature*
Payment:

I would like to pay in full nowI would like to write a check
I am considering the pick-up from school option. Conditions apply.

Yes! Please contact me about this option.
Registration Fee*

$100
Annual Tuition

$1500
Early Bird Special:

$1250
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

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Thank you for applying to JUDA Hebrew Academy by Chabad Pod.
Please note that your registration is not complete until one of us has reached out to you to confirm your child's placement in JUDA.
Please allow us 1-4 business days to contact you.
Looking forward to partnering in your child's Jewish education,

Best,
Rabbi Zevi and Chana Kugel

If you have any questions you can reach us at [email protected]
I would like to receive news and updates by email
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