School Registration

REGISTRATION FOR SCHOOL

2011/2012

Family Name:

Parent/Guardian Name(s):

Street Address:*

City and Zip Code:*

Phone:
(h)
(o)
(c)

Email Address:*

If applicable, additional:

Parent/Guardian Name(s):

Street Address:

City and Zip Code:

Phone:
(h)
(o)
(c)

Email Address:

Student #1

First and Last Name:*

Hebrew Name:

Birth Date:*
JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember 12345678910111213141516171819202122232425262728293031

Current School:

Current School Phone:

Entering Grade*:
Special Talent:

Student #2

First and Last Name:

Hebrew Name:

Birth Date:
JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember 12345678910111213141516171819202122232425262728293031

Current School:

Current School Phone:

Entering Grade:
Special Talent:

Student #3

First and Last Name:

Hebrew Name:

Birth Date:
JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember 12345678910111213141516171819202122232425262728293031

Current School:

Current School Phone:

Entering Grade:
Special Talent:

Please provide further information about your child(ren) of which his/her teacher should be aware, including, but not limited to, special family situation, diagnosed learning disabilities, or education plan.

DO YOU ALLOW YOUR CHILD(REN) TO BE GIVEN:
Adult Strength Tylenol/Advil*: YesNo
Children’s Strength Tylenol/Advil*: YesNo