Registration 2025-26 - Chabad of Maple Valley

How many Children are applying today?*
Child's Name*
Child's Birthday*

Month Day Year
Child's Age in Septemper 2025*
Child's Grade in Septemper 2025*
Child 2 Name*
Child 2 Birthday*

Month Day Year
Child 2 Age in Septemper 2025*
Child 2 Grade in Septemper 2025*
Does your child have any allergies or medical concerns we should be aware of?* If yes, please describe and indicate any precautions necessary
Does your child 2 have any allergies or medical concerns we should be aware of?* If yes, please describe and indicate any precautions necessary
Does your child have a Jewish name, and if yes, please specify what it is*
Does your child 2 have a Jewish name, and if yes, please specify what it is*
Parents Information
Mother's Name*
First Name Last Name
Mother's Cell*
Mother's E-mail*
Father's Name*
First Name Last Name
Father's Cell*
Father's E-mail*
Child's Mother is:*

Jewish from birthConvertedNot Jewish
Child's Maternal Grandmother is:*

Jewish from birthConvertedNot Jewish
Emergency Contact
Full Name*
First Name Last Name
Phone Number*
Relationship to Child*

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Credit Card Number	Security Code
Name on Card
Expiration Month	Expiration Year

Billing Address

Street Address

City

State / Province

Postal / Zip Code

Country

I grant JUDA of Maple Valley permission to use photos of my child on social media and for advertisement purposes. *

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