Family Name

Home Phone No.

______________

Father's Full Name

Address

Postal Code

Cell Phone No.

Business Phone No.

______________

Mother's Full Name

Address

Postal Code

Cell Phone No.

Business Phone No.

Father's Email Address (Home)

Mother's Email Address (Home)

If parents are separated or divorced please indicate child custody arrangement and any restrictions

______________

CHILD 1

English Name

Hebrew Name

Gender
yesno

Date of Birth

Age

Country of Birth

Public School Attending

Grade Entering

Previous Hebrew School Experience

Grade

Requested Classmates (1 per line or comma separated - Max 3)

Food Allergies

Epipen Carried?
yesno

Health Card

Does your child have an IEP or any learning issues? (UJA funding is available if IEP is provided)
yesno

______________

CHILD 2

English Name

Hebrew Name

Gender
yesno

Date of Birth

Age

Country of Birth

Public School Attending

Grade Entering

Previous Hebrew School Experience

Grade

Requested Classmates (1 per line or comma separated - Max 3)

Food Allergies

Epipen Carried?
yesno

Health Card

Does your child have an IEP or any learning issues? (UJA funding is available if IEP is provided)
yesno

______________

The school allows you to request your child to be placed with up to three students of your choice. However, due to the many requests and the small class sizes that we endeavor to maintain, we can only guarantee ONE of your choices. Please make your requested classmates in order of preference.

______________

FAMILY HISTORY

Was the child/children
Born JewishConvertedAdopted

If converted or adopted, please give details:

Language Spoken At Home:

Are You A Member Of A Synagogue?
YesNo

If yes, Name Of Synagogue:

______________

PERSONS TO CONTACT IN CASE OF EMERGENCY

Parents can be reached during Hebrew School Hours At:

Please list two numbers to be used in case of emergencies (other than your home number)

Name

Relationship

Phone

Name

Relationship

Phone

Family Physician

Phone

IF WE, OUR EMERGENCY CONTACT(S), OR OUR PHYSICIAN, CANNOT BE REACHED IN THE EVENT OF A MEDICAL EMERGENCY, WE HEREBY GIVE PERMISSION TO THE PHYSICIAN OR HOSPITAL SELECTED BY THE SCHOOL OR ITS SELECTED REPRESENTATIVE, TO HOSPITALIZE AND/OR SECURE PROPER TREATMENT FOR OUR CHILD/CHILDREN NAMED ABOVE. WE UNDERSTAND THAT ANY COSTS INCURRED WILL BE OUR RESPONSIBILITY.

WE UNDERSTAND THAT ANY COSTS INCURRED BY DAMAGE TO SCHOOL PROPERTY BY OUR CHILD/CHILDREN WILL BE OUR RESPONSIBILITY.

DATE

SIGNATURE (NAME)

Notice to Parents/Guardians and Children � Collection and Release of Information

Information is collected pursuant to the Education Act. Limited information may be disclosed beyond the scope of Ahavat Yisrael Hebrew School. This may include the release of students' names, ages and grades, photographs, artwork, writing or other school related work to the media for publicity, displays, newsletters, etc. If you do not consent to the release of information, please inform the Director of Education in writing prior to the commencement of the school year.

_________________________________________

NEW PARENTS ONLY (REFER A FRIEND PROGRAM):

I/We were referred by: (Their Name)

Phone: (Their Number)