Welcome! We are currently accepting application forms for the 2023-2024 JEC year. If you have any questions or concerns you'd like to discuss with us, please contact us at 310-428-5492. We look forward to a wonderful year of learning and growth. Click here for JEC Dates & Rates. If your child attended our JEC program last year, please click here to fill a returning student form. Please note if you wish to pay by cash/check or zelle, please contact Rabbi Sholom at 347-915-3770 and you will receive a different form. Child's Profile Child's Name* First Name Middle Name Last Name Hebrew Name* Birth Date* 1 - January 2 - February 3 - March 4 - April 5 - May 6 - June 7 - July 8 - August 9 - September 10 - October 11 - November 12 - December Month 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Day 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 Year Time of Birth or Jewish Birthday* Gender* MaleFemale Grade* School* Previous Jewish Education YesNo Where? Hebrew Reading Proficiency NoneSomewhatWell CONFIDENTIAL: Does your child have an IEP or other learning or social challenges? If yes, please describe them and indicate special precautions or care needed. What are your goals in terms of your child's experience at Jewish Enrichment Club? Please number each line with numbers 1 to 5. (1=top priority), and add your own to the list. (0=not a priority) Thank you! Jewish Identity Being in a Jewish environment Hebrew reading Hebrew Language Socializing with Jewish friends Jewish History Knowledge of holidays and traditions Knowledge of Jewish practices/mitzvot Knowledge of basic Jewish prayers Add your own... Family Information Address* Street Address Street Address Line 2 City State / Province Postal / Zip Code Please Select United States Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan The Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Brazil Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile People's Republic of China Republic of China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Cote d'Ivoire Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Eswatini Ethiopia Falkland Islands Faroe Islands Fiji Finland France French Polynesia Gabon The Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati North Korea South Korea Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Islands Poland Portugal Puerto Rico Qatar Romania Russia Rwanda Saint Barthelemy Saint Helena Saint Kitts and Nevis Saint Lucia Saint Martin Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia Somaliland South Africa South Ossetia Spain Sri Lanka Sudan Suriname Svalbard Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tristan da Cunha Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam British Virgin Islands US Virgin Islands Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe Other Country Parent/Guardian 1* First Name Last Name Parent/Guardian 1 Cellphone* Area Code Phone Number E-mail* Primary email Marital Status* MarriedSingleDivorced/Seperated Parent/Guardian 2 First Name Last Name Parent/Guardian 2 Cellphone Area Code Phone Number Parent/Guardian 2 E-mail Is the natural mother and maternal grandmother of the child Jewish?* YesNo *Please note: As JEC is as a Bar & Bat Mitzvah preparation program it is bound by the policies of the central Chabad office as well as the Rabbinical policies of Israel (as are all Jewish lifecycle events). Thereby this specific program is only open to children whose mothers were born Jewish or underwent/ are undergoing an Orthodox conversion. Please feel welcome to join our wide variety of programs at Chabad geared to all. Have there been any conversions or adoptions in the family?* YesNo Please explain conversion/adoption. If there was a conversion, please upload a copy of the certificate below. Please upload a copy of the conversion certificate or email it to [email protected]. How did you hear of us?* Email Facebook Internet Search Attended Previously Friend Other Would you like to register a Second Child YesNo Child's Name* First Name Middle Name Last Name Hebrew Name* Birth Date* 1 - January 2 - February 3 - March 4 - April 5 - May 6 - June 7 - July 8 - August 9 - September 10 - October 11 - November 12 - December Month 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Day 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 Year Time of Birth or Jewish Birthday* Gender* MaleFemale Grade* School* Previous Jewish Education YesNo Where? Hebrew Reading Proficiency NoneSomewhatWell CONFIDENTIAL: Does your child have an IEP or other learning challenges? If yes, please describe them and indicate special precautions or care needed. What are your goals in terms of your child's experience at Jewish Enrichment Club? Please number each line with numbers 1 to 5. (1=top priority), and add your own to the list. (0=not a priority) Thank you! Jewish Identity Being in a Jewish environment Hebrew reading Hebrew Language Socializing with Jewish friends Jewish History Knowledge of holidays and traditions Knowledge of Jewish practices/mitzvot Knowledge of basic Jewish prayers Add your own... Would you like to register a Third Child YesNo Child's Name* First Name Middle Name Last Name Hebrew Name* Birth Date* 1 - January 2 - February 3 - March 4 - April 5 - May 6 - June 7 - July 8 - August 9 - September 10 - October 11 - November 12 - December Month 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Day 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 Year Time of Birth or Jewish Birthday* Gender* MaleFemale Grade* School* Previous Jewish Education YesNo Where? Hebrew Reading Proficiency NoneSomewhatWell CONFIDENTIAL: Does your child have an IEP or other learning challenges? If yes, please describe them and indicate special precautions or care needed. What are your goals in terms of your child's experience at Jewish Enrichment Club? Please number each line with numbers 1 to 5. (1=top priority), and add your own to the list. (0=not a priority) Thank you! Jewish Identity Being in a Jewish environment Hebrew reading Hebrew Language Socializing with Jewish friends Jewish History Knowledge of holidays and traditions Knowledge of Jewish practices/mitzvot Knowledge of basic Jewish prayers Add your own... Emergency Contact Information Emergency Contact* First Name Last Name Phone Number* Area Code Phone Number Relationship* Pediatrician* First Name Last Name Phone Number Area Code Phone Number Medical Insurance* Policy #* CONFIDENTIAL: Does your child have any allergies or other medical condition we should be aware of? If yes, please describe them and indicate special precautions or care needed.* List all persons authorized to pick-up child from school. As the parent(s) or legal guardian of the above child, I/we authorize any adult acting on behalf of the Palisades Jewish Enrichment Club/Chabad 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, the Palisades Jewish Enrichment Club/Chabad 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 the Palisades Jewish Enrichment Club/Chabad activities and that these pictures may be used for marketing purposes. I Accept* Yes Full Name* First Name Last Name Date* We look forward to a wonderful year of fun, learning and growth! Enrollment After you have successfully submitted your application it will be subject to review. We will reach out to schedule a follow up call to discuss your application and confirm it's approval. Once approved a link will be sent to submit tuition to complete your child's enrollment. General Comments Payment Jewish Enrichment Club - Tuesday Afternoons One Child Tuition $1,180 (Sept - May)Two Children Tuition $2,242 (Sept - May)Three Children Tuition $3,304 (Sept - May)JEC Trial Class $36 Optional Donation $180$360$500 Sponsor a Day of Learning$750 Sponsor a JEC Holiday Fun Day$1,180 Sponsor a Child Total $0.00 I would like to pay today:Full amount50% minimum: $0.00 $ Yes, I'd like to donate the cost of processing this transaction by adding 3% Payment Credit Card We accept Visa, MasterCard, American Express, Discover Credit Card Number Security Code Name on Card 1 - January 2 - February 3 - March 4 - April 5 - May 6 - June 7 - July 8 - August 9 - September 10 - October 11 - November 12 - December Expiration Month 2023 2024 2025 2026 2027 2028 2029 2030 2031 2032 Expiration Year Billing Address Street Address Street Address Line 2 City State / Province Postal / Zip Code Please Select United States Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan The Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Brazil Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile People's Republic of China Republic of China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Cote d'Ivoire Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Eswatini Ethiopia Falkland Islands Faroe Islands Fiji Finland France French Polynesia Gabon The Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati North Korea South Korea Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Islands Poland Portugal Puerto Rico Qatar Romania Russia Rwanda Saint Barthelemy Saint Helena Saint Kitts and Nevis Saint Lucia Saint Martin Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia Somaliland South Africa South Ossetia Spain Sri Lanka Sudan Suriname Svalbard Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tristan da Cunha Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam British Virgin Islands US Virgin Islands Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe Other Country Yes, I'd like to make this a monthly recurring payment. 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