JDub Academy Registration Form - 2024

Complete the form below to register your child for JDub Academy classes. Once registration is received, personnel will contact you for payment. Please complete a separate registration form for each child. Questions? Call 217.641.4941.

1Student Information > 2Contact Information > 3Class Registration > 4Waivers
Student's Name Student's Name First Middle Last
Student Date of Birth Student Date of Birth / MM / DD YYYY
Last four digits of student's SSN (or JWCC ID Number)
Has the student taken JDub Academy classes before?

Has the student taken JDub Academy classes before? Yes No
Grade Level (the grade your child will enter this fall)
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Does your child have any known behavioral, medical, or physical conditions, including emotional needs or allergies?

Does your child have any known behavioral, medical, or physical conditions, including emotional needs or allergies? Yes No
If so, please list those conditions.
How did you hear about JDub Academy classes?

How did you hear about JDub Academy classes? Website Booklet School Social Media Other Other
Statistical Information

The State of Illinois requires we collect this information for statistical purposes. These items are required for registration to be complete.
Gender

Gender Male Female
Please identify your child's primary racial/ethnic group.

Please identify your child's primary racial/ethnic group. Asian American Indian or Alaskan Native Black or African American Hispanic or Latino White Native Hawaiian or Pacific Islander Choose not to respond/unknown
Is your child from one or more of the following racial groups? (select all that apply)

Is your child from one or more of the following racial groups? (select all that apply) Asian American Indian or Alaskan Native Black or African American White Native Hawaiian or Pacific Islander Choose not to respond/unknown
Is your child Hispanic or Latino (OR is your child of Spanish origin)?

Is your child Hispanic or Latino (OR is your child of Spanish origin)? Yes, my child is Hispanic or Latino No, my child is not Hispanic or Latino
Is your child a citizen of the United States?

Is your child a citizen of the United States? Yes No
Save my progress and resume later
Enter Your Email Address *

A special link to resume the form will be sent to your email address.

JDub Academy Registration Form - 2024

JDub Academy Registration Form - 2024

Statistical Information