Preschool Nursery Class Application

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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

Mother's Name

First Name Last Name

Mother's Hebrew Name

Mother Jewish

By BirthBy ChoiceOther

Mother's email

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?

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

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/media/pdf/1235/nxGX12350088.pdf

/media/pdf/1235/wKTp12350089.pdf

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Student Application

Parent's Information

Medical Information and Physical History