Application
Student Information
Name
*
First Name
Last Name
Hebrew Name
*
Preferred Name
*
Legal Date of Birth
*
-
Month
-
Day
Year
Date
Hebrew Birthday
*
Email (if student has one)
example@example.com
Applying to:
*
Shiur Aleph Mesivta
Shiur Beis Mesivta
Mechina
What school year are you applying for?
*
5786 / 2025-2026 (current)
5787 / 2026-2027 (upcoming)
Parent/Guardian Information
Who does the student live with?
*
Both Mother & Father
Mother
Father
Alternating
Father's Legal Name
*
First Name
Last Name
Father's Hebrew Name
Father's Email
*
example@example.com
Father's Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Father's Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Is Father's mailing address the same as the home Address?
Yes
No
Father's Mailing Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mother's Legal Name
*
First Name
Last Name
Mother's Hebrew Name
Mother's Email
*
example@example.com
Mother's Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Mother's Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Is Mother's mailing address the same as the home address?
*
Yes
No
Mother's Mailing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Why do you think your child would be a good fit for this program?
*
Is your child a serious student who likes to learn?
*
Education Information
Please provide past 3 schools attended
Current School Name
*
Current School Location
*
Rebbe's Name
*
Current Grades
*
Rebbe's Email
*
example@example.com
Rebbe's Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Reason for Leaving
*
Previous School Name
*
Previous School Location
*
Dates Attended
*
Grades
*
Rebbe's Name
*
Rebbe's Email
*
example@example.com
Rebbe's Phone:
Please enter a valid phone number.
Format: (000) 000-0000.
Reason for Leaving
*
Previous School Name
*
Previous School Location
*
Dates Attended
*
Grades
*
Rebbe's Name
*
Rebbe's Email
*
example@example.com
Rebbe's Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Reason for Leaving
*
Has the applicant ever been asked to leave a school/class? If so, please explain why and what happened from your perspective.
*
Describe your bochur’s internet/technology/smart phone access both home and away.
*
Payment - Application Fee
School Name
School Email
example@example.com
IF PAYING VIA CREDIT CARD ** By providing payment information below, along with my signature at the bottom of this form, I authorize Yeshivas Lubavitch Northwest Florida to charge my credit for the amount indicated in this transaction.
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Application Fee (Non-Refundable)
$150.00
$
150.00
Debit or Credit Card
First Name
Last Name
Credit Card Number
Security Code
Expiration Month
January
February
March
April
May
June
July
August
September
October
November
December
Expiration Month
Expiration Year
2026
2027
2028
2029
2030
2031
2032
2033
2034
2035
2036
2037
2038
2039
2040
2041
2042
2043
2044
2045
Expiration Year
Payment Authorized by Cardholder:
First Name
Last Name
Signature
Date
-
Month
-
Day
Year
Date
YLNWFL
example@example.com
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Submit
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