Ahi Ezer Yeshiva Application

Child's Name

First NameLast Name
Recent Photo of Applicant

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For term beginning September
Division
Hebrew Name
Date of Birth

MonthDayYear
Hebrew Date of Birth
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Place of Birth
Is the applicant a U.S. Citizen?
If the child attended another school, please complete the following:
Previous School
Contact Person
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Judaic Studfies
Achievement Scores
Report Card Uploads

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FAMILY INFORMATION
Applicant's Father
Title
Father's Name

First NameLast Name
Father's Hebrew Name
Father's DOB
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
Occupation
Employer/Business Name
Business Phone
Please enter a valid phone number.Format: (000) 000-0000.
Country of Birth
Applicant's Mother
Mother Address same as Father
Title
Mother's Name

First NameLast Name
Mother's Hebrew Name
Mother's DOB
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
Occupation
Employer/Business Name
Business Phone
Please enter a valid phone number.Format: (000) 000-0000.
Country of Birth
Main language spoken in the home
Are father and mother natural parents of the child?
Marital Status
SHUL AFFILIATION
Congregation
Where you pray during the year
Rabbi Name
Rabbi Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
APPLICANT'S GRANDPARENTS
Father's Side
Titles
Grandfather's Name

First NameLast Name
Grandmother's Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Mother's Side
Titles
Grandfather's Name

First NameLast Name
Grandmother's Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Applicant's Siblings

Please list each sibling's name, age and school
Number of Siblings
Name
Age
School
Name
Age
School
Name
Age
School
Name
Age
School
Name
Age
School
Name
Age
School
Name
Age
School
Please list each sibling's name, age and school
Name Age School Name Age School Name Age School Name Age School Name Age School Name Age SchoolIn the format Name/age/school
IMPORTANT INFORMATION
Does your child receive any special education services?
Please check all that apply.
PLEASE ATTACH A COPY OF THE EVALUATION.

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Does your child have any special needs to which we should be sensitive?
Does your child have any allergies?
Please Explain:
Has your child ever had any serious illness or accident?
Please Explain:
Application Check List
* Complete all sections of the application
* Include a recent photo of your child
* Include non-refundable application fee of $100
* Include a copy of any paperwork from the Department of Education

* If child was in a school last year, please include the following:
- Torah Studies report card from last term
- General Studeies report card from last term
- Copy of last year's Standardized Test Achievement scores

Application Fee

$100
Parent's Signature
Today's Date

MonthDayYear
Date

Payment

Application Fee

$100.00

Total

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

How did you hear about our school?
Should be Empty:

Payment*

Payment