Chai Center for Jewish Life: 2022-2023 Learning Center Registration Form
Please fill out this form to register your child for the K-12 Learning Program.  
***Please submit a separate form for each child.***
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Email *
Student Last Name *
Student First Name *
Gender *
Birthdate *
MM
/
DD
/
YYYY
Hebrew Name
Street Address *
City *
State *
Zip Code *
Home Phone
xxx-xxx-xxxx
Parent/Guardian Email *
Additional Parent/Guardian Email
School Attending for 2022-2023 School Year *
Grade entering in September 2022 *
Parent/Guardian #1 Last Name *
Parent/Guardian #1 First Name *
Parent/Guardian #1 Cell Phone *
xxx-xxx-xxxx
Parent/Guardian #1 Occupation *
Parent/Guardian #1 Religious background *
Parent/Guardian #2 Last Name
Parent/Guardian #2 First Name
Parent/Guardian #2 Cell Phone
xxx-xxx-xxxx
Occupation
Religious background
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