Saiph Stars Application Form

Full Name*

First NameLast Name

Birth Date*

MonthDayYear

Contact #1*

Contact #2*

Email Address *

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Can we contact you via text message?*

YesNo

Can we contact you via WhatsApp?*

YesNo

Games (we currently provide a limited # of games that do not have pop-up ads):*

YesNo

PBS kids games (geared for younger kids such as Curious George):*

YesNo

Zoom:*

YesNo

Please provide your zoom ID and password below (otherwise you will be unable to login given device restrictions)

Tehillim Name *

Please briefly describe your child's situation and how he/she would benefit from the Saiph Stars program? *

How did you hear about us*

Please Note: We offer an option of enabling your child to message specific children who are part of Saiph Stars and are in similar circumstances (based on age/gender, etc.). Additionally, we also can allow a mentor/family/friend/teacher who has an apple device to use the app to message your child. Those who are not part of the Saiph Stars program will be able to upload a limited version of the Saiph Stars app on their own apple device. If you are interested in any of these options, please message us once you receive the iPad through the Shining Stars feature on the app.

Wishing your child a Refuah Sheleimah!

Application

Contact information

Do you want us to include?