BEIS MEDRASH APPLICATION FOR ADMISSION

Application for which year of beis Medrash for the upcoming year? *

Applicant’s English Name: *

First Name Last Name

Applicant’s Hebrew Name: *

Will you require dormitory arrangements? *

YES NO

Date of Birth *

Date

Hebrew Date of Birth: *

Social Security Number: *

Current Yeshiva: *

Father’s Name *

First Name Last Name

Father’s Hebrew Name: *

Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Father's Phone Number *

Please enter a valid phone number.

Home Number *

Please enter a valid phone number.

Cell Number *

Please enter a valid phone number.

Email *

example@example.com

Father's Occupation *

Place of Employment *

Mother's Name *

First Name Last Name

Mother's Hebrew Name *

Mother's Address (If different than above) *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Mother's Home Phone Number *

Please enter a valid phone number.

Cell Number *

Please enter a valid phone number.

Work Number *

Please enter a valid phone number.

Email *

example@example.com

Mother's Occupation *

Place of Employment *

Please List Siblings Of Applicant: *

Shul affiliation, If any: *

If parents are separated, divorced or if either parent is deceased, please indicate.If divorced or separated, applicant lives with: *

Maternal grandparents’ names and address: *

Does applicant have any current health problems or particular disabilities? (If yes, please specify) *

Is the applicant taking any medications? If so, indicate name and dosage: *

Has applicant ever seen a therapist ? If so, written reports must be included. List Name and contact information of therapist: *

Is the applicant current on all Immunizations? *

Has applicant ever been asked to leave a school or not return for the new school year? If yes, please explain: *

Name and Location of Current School *

Current Principal *

Principal's Phone number *

Please enter a valid phone number.

Name of present Rebbe: *

Rebbe's Phone Number *

Please enter a valid phone number.

Please List In Chronological Order All Previous Schools Applicant Has Attended:Include the Name of School & years attended with a complete Address, Phone & fax numbers. Include the names of the Roshei Yeshivos *

Describe the courses ( if applicable) the applicant is taking this year: *

Remittance of an application fee of $50 is non-refundable.

A paper Application can be downloaded at www.azyeshiva.org/beismedrash and should be sent to:
Yeshiva High School of Arizona ~ 7045 N. 12th Street. ~ Phoenix, AZ 85020or by email office@azyeshiva.org

Date

Applicant's Signature

Clear

All applicants must:

1) Enclose copy of birth certificate with application

2) Enclose completed medical forms and emergency contact information with enrollment contract, especially a clear front & back copy of insurance card

3) Bechina with Rabbi Goetz

File Upload

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NOTICE OF NONDISCRIMINATORY POLICY AS TO STUDENTS
Yeshiva High School of Arizona admits Jewish students of any race, coIor, national and ethnic origin to all the rights, privileges, programs, and activities generally accorded or made available to students at the school. It does not discriminate on the basis of race, color, national and ethnic origin in administration of its educational policies, admissions policies, scholarship and loan programs, and athletic and other school
administered program.

BEIS MEDRASH APPLICATION FOR ADMISSION

I. APPLICANT INFORMATION

II. FATHER’S INFORMATION

III. MOTHER’S INFORMATION

IV. OTHER INFORMATION

V. Please Complete – This information is confidential.

VI. Current School