2024-2025 LEC Student Registration

1st Student
Student Name*

First NameHebrew nameLast Name
Date of Birth*

MonthDayYear
Date
Age*
Grade Level for the school year 2024-2025
School Name *
Has student listed above received all required vaccinations? (does not include COVID 19)*

YesNo
Does this student have any allergies (Y/N)*

YesNo
If the student have any allergies, please list them down below
Type N/A if none
Does the student have any medical conditions that you would like to declare?
Student Accommodation
Does the student above need any accommodations? Ex.: vision, hearing, learning, or other needs

2nd Student
Student Name

First NameHebrew nameLast Name
Date of Birth

MonthDayYear
Date
Age
Grade Level for the school year 2024-2025
School Name
Has student listed above received all required vaccinations? (does not include COVID 19)

YesNo
Does this student have any allergies (Y/N)

YesNo
If the student have any allergies, please list them down below
Type N/A if none
Does the student have any medical conditions that you would like to declare?
Student Accommodation
Does the student above need any accommodations? Ex.: vision, hearing, learning, or other needs

3rd Student
Student Name

First NameHebrew nameLast Name
Date of Birth

MonthDayYear
Date
Age
Grade Level for the school year 2024-2025
School Name
Has student listed above received all required vaccinations? (does not include COVID 19)

YesNo
Does this student have any allergies (Y/N)

YesNo
If the student have any allergies, please list them down below
Type N/A if none
Does the student have any medical conditions that you would like to declare?
Student Accommodation
Does the student above need any accommodations? Ex.: vision, hearing, learning, or other needs

4th Student
Student Name

First NameHebrew nameLast Name
Date of Birth

MonthDayYear
Date
Age
Grade Level for the school year 2024-2025
School Name
Has student listed above received all required vaccinations? (does not include COVID 19)

YesNo
Does this student have any allergies (Y/N)

YesNo
If the student have any allergies, please list them down below
Type N/A if none
Does the student have any medical conditions that you would like to declare?
Student Accommodation
Does the student above need any accommodations? Ex.: vision, hearing, learning, or other needs

Parent/Guardian's Information
Parent/Guardian's Name - Primary*
First and last name
E-mail*
Mobile Number*
Alternate Number
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian's Name - Secondary*
First and last name
E-mail*
Mobile Number*
Alternate Number
Please enter a valid phone number.
In case of emergency, who will be notified? Please answer the fields below:
Emergency Contact Person*
First and last name
Relationship to Student*
Emergency Phone Number*
Please enter a valid phone number.
Authorized Pick-Up?*
Other than parent(s), who may pick up your child from school? If none, enter N/A

Medical Release
Medical Release: Please select one: "I agree" or "I disagree"

In the event of an emergency, I hereby give qualified medical personnel permission to secure proper treatment for my child(ren), including, if necessary, hospitalization. I understand that I will be contacted immediately in such a case.
Medical Release*

I agreeI disagree
Record of immunizations If you can't upload the file please sent it to LEC email: lec@ahavathsholom.org

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