BEIS MEDRASH APPLICATION FOR ADMISSION

BEIS MEDRASH APPLICATION FOR ADMISSION

7045 N 12th Street., Phoenix , Arizona 85020 602-266-1213 1 800 660-0335(fax)
I. APPLICANT INFORMATION
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 *

Month Day Year
Date
Hebrew Date of Birth: *
Social Security Number: *
Current Yeshiva: *
II. FATHER’S INFORMATION
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 *
III. MOTHER’S INFORMATION
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: *
IV. OTHER INFORMATION
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: *
V. Please Complete – This information is confidential.
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: *
VI. Current School
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

Month Day Year
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
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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.
Should be Empty:

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