Challah Days (Pre-K)

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* Child's First Name:

* Child's Last Name:

Hebrew Name:

* Address:

* City:

* Zip:

* Gender:

* Age:

* Date of Birth:

* Parent's Marital Status:

* Primary email used for communication:

Secondary email (optional):

* Parent/Guardian 1 First Name:

* Parent/Guardian 1 Last Name:

Parent/Guardian 1 Hebrew Name:

Parent/Guardian 1 Home Phone Number:

Parent/Guardian 1 Work Phone Number:

* Parent/Guardian 1 Mobile Phone Number:

Parent/Guardian 2 First Name:

Parent/Guardian 2 Last Name:

Parent/Guardian 2 Hebrew Name:

Parent/Guardian 2 Home Phone Number:

Parent/Guardian 2 Work Phone Number:

Parent/Guardian 2 Mobile Phone Number:

Are there any custody arrangements that we need to be aware of?

Sibling Name (not yet enrolled in Religious School):

Sibling Birth Date:

Sibling Name (not yet enrolled in Religious School):

Sibling Birth Date:

Does your child have a diagnosed learning disorder/challenge (dyslexia, processing disorder, etc.)?

Does your child have a medical diagnosis (asthma, allergies, hearing problems, vision problems, etc.). If so, does your child require an Epipen? If yes, please let us know and we can keep an extra one here if desired.

Does your child have a diagnosed mental health condition (ADHD, depression, anxiety)?

Does your child take medications for any of the aforementioned conditions? If yes, please list them here.

Would you like to have a call or meeting with your child's Challah Days teacher before school to discuss any of the above?

YesNo

Name two emergency contacts who will assume temporary care of your child in an emergency or lockdown situation, only if you cannot be reached.

* Emergency Contact 1 Name:

Emergency Contact 1 Home Phone Number:

Emergency Contact 1 Mobile Phone Number:

* Emergency Contact 2 Name:

Emergency Contact 2 Home Phone Number:

Emergency Contact 2 Mobile Phone Number:

* Name of Child's Physician:

* Physician's Phone Number:

* Media Consent for the 2025-2026 School Year: PBJC Religious School is proud of the many programs, events and educational opportunities we offer. At various points throughout the school year, your child may be photographed or videoed for publicity and/or announcement purposes. Media Consent grants permission for your students photo/image to be published in PBJC publications and newsletters, social media, or other online or print news publications or social media

Please Select OneYes, I grant Media Consent for my child for the 2025-2026 school year.No, I do not grant Media Consent for my child for the 2025-2026 school year.

* Virtual Signature. By writing my name below, I hereby give my consent to the Religious School Director/Administrator, or person designated as such, to make available to my child professional emergency medical care if such care is indicated. It is understood that a conscientious effort will be made to notify my spouse or me before such action is taken. It is further understood that every effort will be made to contact my child's physician prior to any treatment. However, in the event that this is not possible, I give my permission for my child to receive proper medical care by any doctor, nurse, ambulance personnel, paramedic or member of the medical staff of a hospital licensed by the Sate of New Jersey. This is also to certify that my child is in good physical health. He/she has my permission to participate in all activities (including field trips) that are part of the Religious School program.

* Payment Amount ($400 full payment for PBJC Members, $500 full payment for Non-Members):

Please Select OneFull Challah Days Tuition for PBJC Member ($400)Full Challah Days Tuition for Non-Member ($500)2025-2026 Religious School Challah Days Payment

Wed, August 20 2025
26 Av 5785

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Wed, August 20 2025 26 Av 5785