Register

Total Students to Register*
Student 1
Full Name*
First Name Last Name
Hebrew Name
Birth Date*

Month Day Year
School Name*
Grade Entering*
Hebrew Reading Proficiency*

None at allSomewhatProficient
Previous Jewish Education*

YesNo
Where was previous Jewish education?*
Student 2
Full Name*
First Name Last Name
Hebrew Name
Birth Date*

Month Day Year
School Name*
Grade Entering*
Hebrew Reading Proficiency*

None at allSomewhatProficient
Previous Jewish Education*

YesNo
Where was previous Jewish education?*
Parents' Info
Father's Name*
First Name Last Name
Father's Cell*
Father's Email*
Mother's Name*
First Name Last Name
Mother's Cell*
Mother's Email*

Address*

Street Address
Street Address Line 2
City	State
Zip Code	Country

Home Phone*
Is child's biological father Jewish?*

YesNo
Is child's biological mother Jewish?*

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

YesNo
Please provide conversion or adoption details*
Photo Consent

I authorize JUDA of Rockland to photograph my child and to use these photos for promotional purposes.
Medical & Emergency Info
Emergency Contact 1*
First Name Last Name
Phone Number*
Emergency Contact 2*
First Name Last Name
Phone Number*
Does your child(ren) have any allergies or other medical condition we should be aware of?*

YesNo
Please describe the condition and indicate special precautions or care needed*
MEDICAL AGREEMENT

As the parent(s) or legal guardian of the above child, I/we authorize any adult acting on behalf of JUDA of Rockland 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, JUDA of Rockland personnel will try, but are not required, to communicate with me prior to such treatment. I hereby give permission for my child to participate in all school activities, join in class and school trips on and beyond school properties and allow my child to be photographed while participating in JUDA of Rockland activities and that these pictures may be used for marketing purposes.
Initialize as agreement*
Payment Info
Your application is not complete without a payment plan. JUDA of Rockland does not reject anyone due to lack of funds. If you feel that you need a special payment plan, please email [email protected] or call our office at 845-356-6686.
Payment Options*

Pay in full todayPay in two installments - half today and half on January 1Pay in ten installments - the first payment today and 9 payments each month thereafter for 9 consecutive monthsAs per our discussion, an alternative payment plan has been arranged
Amount to Charge Today*

$

Payment

Credit Card Paypal Check

Postal / Zip Code

Country

Should be Empty:

This page uses TLS encryption to keep your data secure.

Updates

Lorem ipsum is simply

Lorem Ipsum is simply dummy text of the printing and typesetting industry.

Educate Your Child... Educate a Generation

Student 1

Student 2

Parents' Info

Medical & Emergency Info

Payment Info