JYC Application Form 2018-2019
Your Name *
Your answer
How many children do you plan on registering for JYC? *
Child #1Name *
Your answer
Is child #1 a new or existing JYC student? *
Gender *
Child's Date of Birth *
MM
/
DD
/
YYYY
Grade completed in 2017-2018 *
Your answer
Home Address *
Your answer
City *
Your answer
State *
Your answer
Zipcode *
Your answer
Home Phone *
Your answer
Mother's Name *
Your answer
Mother's Hebrew Name (If Known)
Your answer
Father's Name *
Your answer
Father's Hebrew Name (If Known)
Your answer
Mother's Cell *
Your answer
Father's Cell *
Your answer
Mother's Email *
Your answer
Father's Email *
Your answer
Mother's Occupation
Your answer
Father's Occupation
Your answer
Grandparent's Names (Grandmother & Grandfather) *
Your answer
Grandparent's Email *
Your answer
Grandparent's Email # 2
Your answer
Current School Attending *
Your answer
Reference name and phone number at your child's current school *
Your answer
Current Summer Camp (If Applicable)
Your answer
Emergency Contact Name *
Your answer
Phone Number *
Your answer
Email Address *
Your answer
Relationship to Student *
Your answer
Physician's Name *
Your answer
Physicians Phone Number *
Your answer
Health Insurance Company *
Your answer
Family Synagogue Affiliation
Your answer
Do you have another child that you would like to register for JYC at this time? *
Child # 2 Name
Your answer
Child # 2 Gender
Child # 2 Date of Birth
MM
/
DD
/
YYYY
Child # 2 Grade completed in 2017-2018
Your answer
Current School Attending
Your answer
Reference name and phone number from current school
Your answer
Child # 3 Name
Your answer
Child # 3 Gender
Child # 3 Date of Birth
MM
/
DD
/
YYYY
Child # 3 Grade completed in 2017-2018
Your answer
Current School Attending
Your answer
Reference name and phone number of current school.
Your answer
Do any of your children receive any special services at secular school, such as special education classes, resource room pull-out programs, or any other services? *
If yes, please specify. (This will be kept 100% confidential.)
Your answer
Please provide the service coordinator's contact info (email and phone) so we could ensure we establish the necessary supports.
Your answer
Did someone recommend the program to you? If so, please provide their name. *
Your answer
By checking this box we understand that it is the practice of the School to use photographs, recordings, videos and quotations of students in its publications and in other selected media, for the purpose of promoting the school and its programs. We agree that as parents, we give permission to use such photographs, video, recordings, and quoted material in JYC publications or other selected media unless we specifically notify the school in writing to the contrary. *
Required
Parents signature *
Your answer
Date *
MM
/
DD
/
YYYY
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