Pico Mesivta Enrollment Form

The New Yeshiva High School of
Los Angeles
(Name to be determined- available for dedication)
New Student Enrollment Form
Student Information

Please note: This application should be completed by a parent or legal guardian.
Legal Name*

First NameLast Name
Preferred Name*
Name applicant is called
Date of Birth*

MonthDayYear
Date
Please provide a clear headshot of the student only*

Cancelof

General Health Information
Name of Physician*
Phone Number of Physician*
I release the school of all liability that may arise from emergency medical treatment for my son.
Parent Signature
Does your son take any medications?*

YesNo
Please explain in the space provided below:
Does your son have any allergies?*

YesNo
Please explain in the space provided below:
Does your son have any physical or learning disabilities?*

YesNo
Please explain in the space provided below:
Are there any special circumstances in your medical history, family life, or emotional development that we should know about?*

YesNo
Please explain in the space provided below:

Financial Information:

The Yeshiva is very dedicated to providing a warm and nurturing environment where the students can grow and achieve their fullest potential.

Registration Fee	$1,000
Tuition Fee*	$23,500

*Please note that the tuition fee includes $3,600 Membership Fee.

Tuition will be paid over 10 months from August- May.

Name*

First NameLast Name
I have read and agree to the above details regarding tuition.*
Who will be paying tuition for this student?*
*

Full Tuition- I hereby agree to pay the fees as indicated aboveTuition Assistance- I hereby request Tuition Assistance

Payment*

Non-Refundable Enrollment Fee

$1,000.00

Total

$0.00

Student Information