Application for Admission

Application for Admission

2024-2025
Perspective Student Information
I wish to be admitted to Grade * for the * school year.
Student Name - English*

First NameLast Name
Student Name - Hebrew*
Place of Birth*
Date of Birth - English*

MonthDayYear
Date
Date of Birth - Hebrew*
Social Security Number*
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone*
Please enter a valid phone number.
Student Cell Phone
Please enter a valid phone number.
Student Email Address*
example@example.com
Does the student currently live at home with her parents? If no, please explain. *
Current School*
Current Grade*

8th9th10th
Please upload applicant's most recent report cards including Judaic and General Studies. *

Cancelof
Please upload applicant's previous years' report card include Judaic and General Studies. EX: If applicant is in 8th grade, please submit 7th grade report cards here.*

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Family Information

Please list the names, ages, schools and grades of all children in the family
Name* Age*    School*    Grade*
Name*   Age*   School*   Grade*
Name*   Age*   School*   Grade*
Name*   Age*   School*   Grade*
Name*   Age*   School*   Grade*
Name*   Age*   School*   Grade*
Name*   Age*   School*   Grade*
Name*   Age*   School*   Grade*
Previous Schools

Please list all schools that applicant has attended. Enter 0 for any remaining fields.
School*   Grades Attended*   Years Attended*
School*   Grades Attended*   Years Attended*
School*   Grades Attended*   Years Attended*
School*   Grades Attended*   Years Attended*
School*   Grades Attended*   Years Attended*
Summer Camps

Please list all schools that applicant has attended. Enter 0 for any remaining fields.
Camp*   Years Attended*   Position Held*
Camp*   Years Attended*   Position Held*
Camp*   Years Attended*   Position Held*
Camp*   Years Attended*   Position Held*

Personal Information

Confidential When Completed and Signed Please note: In order to provide the most appropriate educational environment for your daughter, it is crucial for the school to have a full picture of your daughter's educational and medical background. Please indicate not applicable where necessary.
Please list all medication that your daughter takes on a regular basis, including non-prescription drugs and vitamins and their frequency.*
Please list all major operations/surgeries relevant to school life and activities.*
Has your daughter ever been assessed educationally or psycho-educationally?*
If you answered yes to the previous question, please upload assessment documents such as an IEP, or neuro-psych evaluation.

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Before submitting an application, all prospective students and their parents must read through the Chaviva Student and Parent Guidebook here: Please acknowledge that you have done so below.
Signature of Parent*

Clear
Signature of Student*

Clear
Date*

MonthDayYear
Date

Please list 2 people who can be contacted as references

References should not be a relative of the applicant.
Reference 1 - someone who can speak of the applicant as a student in the classroom*

First NameLast Name
Reference 1 Relationship to Applicant*
Reference 1 Phone Number*
Please enter a valid phone number.
Reference 2 - someone who can speak of the applicant's character as a Bas Yisrael*

First NameLast Name
Reference 2 Relationship to Applicant*
Reference 2 Phone Number*
Please enter a valid phone number.
Should be Empty:

Perspective Student Information