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Preschool Application Form

Student Application
Which class are you applying for?*
Student's Full Name*
First Name Last Name
Student's Gender*

MaleFemale
Student's Hebrew Name
Student's Birth Date*

Month Day Year
Time of Birth
Hour Minutes
Please Upload a Current Photo of your Child*

Address*

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Parent's Information
Mother's Name*
First Name Last Name
Mother's Hebrew Name
Mother Jewish*

By BirthBy ChoiceOther
Mother's email*
I would like to receive news and updates from Chabad at Short Hills by email. I understand that information I provide to Chabad at Short Hills will be used according to its Privacy Policy and I can unsubscribe at any time.
Mother's Cell*
Mother's Occupation
Mother's Work Number
Father's Name*
First Name Last Name
Father's Hebrew Name
Father Jewish *

By BirthBy ChoiceOther
Father's email*
Father's Cell*
Father's Occupation
Father's Work Number
Are Parents*
Are there any conversions or adoptions in the family*
If yes please explain
Synagogue of Affiliation *
Language spoken at home if not English
Brothers Living at Home
Sister Living at Home
Does anyone else assume occasional responsibility for the care of your child?*

YesNo
If yes, by what name is this person known to your child?
Authorized Person to Pick Up from School
Person 1 Full Name
Relationship to Child
Phone Number
Person 2 Full Name
Relationship to Child
Phone Number
Medical Information and Physical History
Pediatrician's Name*
First Name Last Name
Pediatrician's Phone Number*
Is your child currently receiving medical treatment?*

YesNo
If yes please explain
Medications your child takes on a regular basis
What physical condition might limit your child's participation in school?
Is your child allergic or sensitive to insect stings or bites?

YesNo
Does your child require the use of an epipen?

YesNo
Is your child allergic or sensitive to any medication?

YesNo
Is your child allergic or sensitive to any foods? *

YesNo
Is your child allergic or sensitive to anything else?

YesNo
If you answered yes to any of the above please list here
Does your child have hearing loss?

YesNo
Does your child have a history of ear infections?

YesNo
Does your child wear glasses?

YesNo
Has your child had a history of respiratory infections?

YesNo
Does your child have a speech or language delay?

YesNo
Has your child ever received any of the following services?

SpeechOTPT
Is there anything you would like us to know about your child's behavior, habits or activities?
Does your child exhibit any fears you are aware of?

YesNo
If yes please explain
Does your child exhibit any of the following?

Thumb suckingTantrumsBiting
Who will accompany your child to school? *

ParentCaretakerCarpoolOther
Do you anticipate a separation problem?

YesNo
How does your child react when separating from parents?
Does your child still nap?

Regularly?Sometimes?Rarely
How does your child relate to other children?
Has your child attended any other Early Childhood Programs? *

YesNo
If yes please explain
Is your child toilet trained?

YesNoWorking on it
What are your child's interests?
What special concerns might you have in terms of your child?
Please list any other information that will aid us in working more effectively with your child?
MEDICAL FORMS

PLEASE PRINT, FILL OUT AND UPLOAD

[email protected]

UNIVERSAL MEDICAL FORM

NJ IMMUNIZATION FORM
Upload Universal Medical Form*
Upload Immunization Form*
Please access the link and read the Parent Handbook

Gan Parent Handbook

if unable to access use the following link

https://drive.google.com/file/d/1iQx6QqVhbb-Yrd3UDuLWEjaC7a15RlpN/view?usp=sharing
Please check the following box*

I have read a copy of The Gan’s Parent Handbook. I understand I am completely responsible for reading the Parent Handbook in its entirety before my child’s first day of attendance and should I have any questions or require clarification of any of the content, I am responsible for contacting Chaya Weisberg. I am aware that this Parent Handbook is not inclusive and is subject to change
Please read and check all the boxes*

I am responsible for adhering to the policies and procedures as presented in the Parent Handbook.I am aware that the Parent Handbook outlines the following: Discipline Policy, Expulsion Policy, Healthy Foods Policy, Communicable Disease Policy, Social Media Policy and Policy on the Release of Children.I have received and read a copy of the Expulsion Policy from The Gan- This needs a link to your policyI am aware that my child’s file, including medical information and emergency contact information, must be kept up-to-date at all times.
Early Bird Application (Jul 15th, 2026)*

$300
Total

$0.00

Payment

Credit Card

We accept Visa, MasterCard, American Express, Discover
Credit Card Number	Security Code
Name on Card
Expiration Month	Expiration Year

Billing Address

Street Address

City

State / Province

Postal / Zip Code

Country

SPECIAL FIRST YEAR Introductory Tuition Rate - $8,000

Our office will contact you with payment options after receiving application.
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Student Application

Parent's Information

Authorized Person to Pick Up from School

Medical Information and Physical History

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