2016-2017 Religious & Hebrew School Registration Form
Student 1 - First Name *
Your answer
Student 1 - Last Name *
Your answer
Student 1 - Birthdate *
MM
/
DD
/
YYYY
Student 1 - Gender *
Required
Student 1 - Hebrew Name
Transliteration - ex. Yosef
Your answer
Student 1 - Name of Public School attending in 2016-2017 *
Your answer
Student 1 - Grade in Public School in 2016-2017 *
Required
Student 1 - Grade & Day in Religious School in 2016-2017 *
Required
Student 1 - Grade & Day in Hebrew School in 2016-2017
Does your child have medical restrictions? *
Your answer
Physician's Name *
Your answer
Physician's Phone Number *
Format xxx-xxx-xxxx
Your answer
What are some of your child's hobbies and interests?
Your answer
What is your child's favorite thing about being Jewish? (holiday, story, food, song, prayer, etc)
Your answer
How does your child learn best? (ex. visual auditory, kinesthetic, work well in a quiet space, prefer sitting up front, etc,)
Your answer
Tell us about your child as a learner: Strengths
Please list your child's strengths as a learner
Your answer
Tell us about your child as a learner: Challenges
Please list your child's challenges as a learner
Your answer
If your child is currently receiving special services in public school, please mark below:
If you answered yes that this child is recieving services in public school. Please tell us how your child is impacted and supported in a learning enviroment?
Your answer
Which of the following medical conditions apply to your child? (Choose all that apply)
List any Allergies for this child
Your answer
List any Medical Conditions that have not been noted yet
Your answer
Is there anything special we should do if the above problem arises?
Your answer
Does your child take any medication?
Please list medications taken by your child
Your answer
Is your child afraid of loud noises?
Is your child afraid of flashing lights?
Is there anything else you would like to share about your child?
Your answer
Are there any students your child should NOT be placed with?
Please write the name(s) here
Your answer
Additional Student to Register *
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