Family Info Father's Name* First Name Last Name Father's Email* Father's Phone Number* Area Code Phone Number Is the Father Jewish?* YesNo Mother's Name* First Name Last Name Mother's Email* Mother's Phone Number* Area Code Phone Number Is the Mother Jewish?* YesNo Child's Primary Address* Street Address Street Address Line 2 City State / Province Postal / Zip CodePlease SelectUnited StatesAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanThe BahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChilePeople's Republic of ChinaRepublic of ChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCook IslandsCosta RicaCote d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonThe GambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern MarianaNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint BarthelemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSomalilandSouth AfricaSouth OssetiaSpainSri LankaSudanSurinameSvalbardSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTristan da CunhaTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamBritish Virgin IslandsUS Virgin IslandsWallis and FutunaWestern SaharaYemenZambiaZimbabweOther Country Marital Status of Parents* SingleMarriedDivorcedWidowedOther Any conversions in the family?* YesNo If so, please explain:* Child Information How many children are you registering?* Child #1 Child #1 legal name* Child #1 Hebrew name if known Child #1 Date of Birth* 1 - January2 - February3 - March4 - April5 - May6 - June7 - July8 - August9 - September10 - October11 - November12 - December Month12345678910111213141516171819202122232425262728293031 Day2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 Year Please indicate time of birth as:* this helps determine the Hebrew birthday Before sunsetAfter sunsetUnknown School child #1 is attending in the fall:* Grade child #1 is entering in the fall:* Kindergarten1st2nd3rd4th5th6th7th8th Is child #1 adopted?* YesNo List any medications Child #1 takes:* enter N/A if not applicable List any allergies Child #1 has to food or medications:* enter N/A if not applicable Does child #1 need an epi-pen?* YesNo Does child #1 have any medical, developmental or behavioral issue that we should know about?* YesNo If so, please explain:* Can child #1 read basic Hebrew?* YesNo Child #2 Child #2 legal name* Child #2 Hebrew name if known Child #2 Date of Birth* 1 - January2 - February3 - March4 - April5 - May6 - June7 - July8 - August9 - September10 - October11 - November12 - December Month12345678910111213141516171819202122232425262728293031 Day2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 Year Please indicate time of birth as:* this helps determine the Hebrew birthday Before sunsetAfter sunsetUnknown School child #2 is attending in the fall:* Grade child #2 is entering in the fall:* Kindergarten1st2nd3rd4th5th6th7th8th Is child #2 adopted?* YesNo List any medications Child #2 takes:* enter N/A if not applicable List any allergies Child #2 has to food or medications:* enter N/A if not applicable Does child #2 need an epi-pen?* YesNo Does child #2 have any medical, developmental or behavioral issue that we should know about?* YesNo If so, please explain:* Can child #2 read basic Hebrew?* YesNo Child #3 Child #3 legal name* Child #3 Hebrew name if known Child #3 Date of Birth* 1 - January2 - February3 - March4 - April5 - May6 - June7 - July8 - August9 - September10 - October11 - November12 - December Month12345678910111213141516171819202122232425262728293031 Day2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 Year Please indicate time of birth as:* this helps determine the Hebrew birthday Before sunsetAfter sunsetUnknown School child #3 is attending in the fall:* Grade child #3 is entering in the fall:* Kindergarten1st2nd3rd4th5th6th7th8th Is child #3 adopted?* YesNo List any medications Child #3 takes:* enter N/A if not applicable List any allergies Child #3 has to food or medications:* enter N/A if not applicable Does child #3 need an epi-pen?* YesNo Does child #3 have any medical, developmental or behavioral issue that we should know about?* YesNo If so, please explain:* Can child #3 read basic Hebrew?* YesNo Child #4 Child #4 legal name* Child #4 Hebrew name if known Child #4 Date of Birth* 1 - January2 - February3 - March4 - April5 - May6 - June7 - July8 - August9 - September10 - October11 - November12 - December Month12345678910111213141516171819202122232425262728293031 Day2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 Year Please indicate time of birth as:* this helps determine the Hebrew birthday Before sunsetAfter sunsetUnknown School child #4 is attending in the fall:* Grade child #4 is entering in the fall:* Kindergarten1st2nd3rd4th5th6th7th8th Is child #4 adopted?* YesNo List any medications Child #4 takes:* enter N/A if not applicable List any allergies Child #4 has to food or medications:* enter N/A if not applicable Does child #4 need an epi-pen?* YesNo Does child #4 have any medical, developmental or behavioral issue that we should know about?* YesNo If so, please explain:* Can child #4 read basic Hebrew?* YesNo Pick-up Authorization List name(s) of those, other than parents, who are authorized to pick up your child(ren) from school: Payment info Non-refundable Deposit: $100 per child. Tuition: $400/Month per child. Tuition will be collected once a month on the 15th of every month. Promo Code: How many children are you registering?* How many children are you registering?* 10% discount applied How many children are you registering?* 20% discount applied Total Deposit + Tuition (tuition payment will not be processed until registration is confirmed) $0.00 Payment* ⚠ You have not yet connected a credit card processor.Credit Card We accept Visa, MasterCard, American Express, Discover Credit Card Number Security Code Name on Card1 - January2 - February3 - March4 - April5 - May6 - June7 - July8 - August9 - September10 - October11 - November12 - December Expiration Month2025202620272028202920302031203220332034 Expiration Year Is the billing address the same as listed above?* YesNo Billing Address* Street Address Street Address Line 2 City State / Province Postal / Zip CodePlease SelectUnited StatesAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanThe BahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChilePeople's Republic of ChinaRepublic of ChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCook IslandsCosta RicaCote d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonThe GambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern MarianaNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint BarthelemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSomalilandSouth AfricaSouth OssetiaSpainSri LankaSudanSurinameSvalbardSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTristan da CunhaTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamBritish Virgin IslandsUS Virgin IslandsWallis and FutunaWestern SaharaYemenZambiaZimbabweOther Country Questions or comments regarding payment: Enrollment Agreement To enroll your child(ren) in Chabad West Boca After School all forms must be submitted with the required fees. Enrollment is considered to be for the entire school year. The school cannot issue refunds or credits for illness, holidays, family vacations, or early withdrawal. In the event that the school is closed due to or resulting from a weather emergency or other unforeseen circumstances, there will be no make-up days, refunds or credits for days that school is not in session. Upon processing a tuition payment, if sufficient funds are not available or the credit card is not approved, your account will be charged $25 for each transaction that could not be processed. Parent(s) acknowledge that Chabad After School serves children who are able to function successfully in a group setting. If, in the judgement of the school's Director, the child is not able to function in a group setting, the parent may be asked to withdraw the child. In the event that the parent is requested to withdraw the child, the Director will work with the parent to identify possible alternative programs suitable for the child. We give permission for the use of photographs of our child(ren) in print materials, on our website, social media and/or emails. Last names of children are never listed. We give permission for our name and telephone number(s) to be included in any class list that may be distributed. Medical Emergencies I hereby give permission, in the event of an emergency, for the Director, Acting Director, or the Teacher at Chabad After School to take whatever steps may be necessary for the medical care of my child. I understand that in order for Chabad After School to assume responsibility for my child, I, or the person(s) whom I have designated to drop off and pick up my child, must sign my child in at the time of arrival and out at the time of departure. I understand that unless there is a need for immediate action, the order of the steps taken will follow, but will not be limited to, the outline below: 1. The parent/guardian will be called. Note: If the parent/guardian is unavailable, the emergency contact person designated by the parent/guardian will be called. 2. If these efforts are unsuccessful the following steps will be taken (order may vary depending on the situation): a. A physician will be called. b. The child will be taken to the nearest emergency room accompanied by a staff member. c. An ambulance will be called to take the child to the nearest emergency room accompanies by a staff member. In the event of an emergency, if I cannot be reached, I give consent for a Chabad staff member to transport my child to the nearest emergency facility, or to have my child transported by ambulance. I give consent to any emergency facility and physician to administer any necessary medical treatment to my child as the situation may warrant it. Emergency Contact Name* First Name Last Name Emergency Contact Cell Phone* Area Code Phone Number If parents cannot be reached and emergency medical advice is needed, permission is given to Chabad After School staff to phone my child's doctor. In case of a medical emergency requiring immediate emergency care, I authorize the paramedics to take my child to the nearest hospital, if necessary. It is understood that I will hold Chabad West Boca After School harmless for the nature and outcome of any emergency medical treatment. It is also understood that I leave the decision of what constitutes an emergency to the sole direction of the staff. Parent Electronic Signature I have provided information, consent, authorization and agreement where indicated, and the information I provided is accurate. Type first and last name of parent completing this form, to be used as your electronic signature.* First Name Last Name Please send a confirmation email to:* Submit Should be Empty: This page uses TLS encryption to keep your data secure.
This page uses TLS encryption to keep your data secure.
