Keser Academy Application Form

Keser Academy Application Form

Complete all applicable student, parent, medical, and family background fields.
Please save your application as you go.

This application will ask for student, family, religious background, educational, learning, social and emotional, and medical information. The following documents will need to be uploaded to the application as well (if applicable).
- Report cards from the past two school years
- Recent photograph of the student
- Custody agreement (if applicable)
- Conversion paperwork (if applicable)
There is a non-refundable application fee of $150/student, which will be collected on the last page of the form.
Student Information
Legal First and Middle Name
Legal Last Name
Birthday

MonthDayYear
Date
Hebrew Birthday - Day and Month
Grade Applying For
Child's Preferred Name
Hebrew First and Middle Name
Upload a photo of your daughter.

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Child's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Who is completing this form?

Child’s Educational Information
Why are you seeking a new school for your daughter at this time?
School(s) your child previously attended. Has your daughter ever repeated a grade, been asked to leave a school or been placed below grade level?
Principal/Teacher at Previous School
Principal/Teacher Phone
Please enter a valid phone number.Format: (000) 000-0000.
Principal/Teacher Email
example@example.com
Upload Report Cards from the Last 2 Years

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Developmental Profile
In which subjects (Judaic and General Studies) does your daughter shine? Are there any areas in which she struggles or needs additional support? Please elaborate.
We recognize that grades and standardized tests do not always capture a student’s true abilities. How would you describe your daughter’s strengths, talents and potential beyond what may be reflected in her academic record?
Describe your daughter’s friendships and social life, detailing her interactions with peers. Describe your daughter’s personality, strengths, interests and talents. What does she like to do outside of school? (Sports, arts, music, hobbies and chesed?)
Does the applicant have any known or suspected physical, mental health, behavioral, psychological, or academic concerns or diagnosed conditions?
Please explain:
Has the applicant previously undergone an educational or psychological evaluation?
Please explain:
Has your daughter ever received occupational, speech-language, physical, behavioral, and/or mental health therapy?
Please explain:
Does your daughter take any medication relevant to her learning wellbeing?
Which medication(s)?
Please provide the professional’s name and contact information (with your permission to contact)
Please provide three (3) references. At least one should be from her current or most recent school.
Upload Standardized Testing Results (if available)

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Upload Psychoeducational or other evaluation reports (if applicable)

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Upload IEP / 504 plan or accommodation documentation (if applicable)

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REMINDER: SAVE YOUR PROGRESS! Click the "Save" button below.

Medical Information
Does your Child have any medical conditions? Please detail condition and any medications taken for it.
Does your child take daily medication? Please detail which ones, what they are taken for and how often.
Is your daughter up to date on her vaccinations?
Emergency Contact Relationship to Child
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Name of Pediatrician
Pediatrician Office Phone Number
Please enter a valid phone number.Format: (000) 000-0000.

Signature
What happens next: Once we receive your completed application, our intake team will review it and contact you to schedule a family meeting and a student visit.
We certify that the information provided in this application is complete and accurate to the best of our knowledge. We understand that acceptance is determined individually based on the information we submit about our daughter and that withholding relevant information may affect the school’s ability to serve her. We authorize Keser Academy to confidentially contact the references, Rabbis and schools listed above.
Please type Father/Guardian’s name and Mother/Guardian’s name and date applying. Please sign in spaces below.
Father’s/Guardian Signature
Mother’s/Guardian Signature

Payment

Application Fee

$150.00

Enter coupon

Total

Payment Methods

Debit or Credit Card

Choose from one of the PayPal options to make your payment.

Should be Empty:

Keser Academy Application Form

Student Information

Family, Religious, and Background Information

Father Information

Mother Information

Child’s Educational Information

Developmental Profile

Medical Information

Signature

Payment

Application Fee

Payment Methods

Keser Academy Application Form

Student Information

Family, Religious, and Background Information

Father Information

Mother Information

Child’s Educational Information

Developmental Profile

Medical Information

Signature

Payment

Application Fee*

Payment Methods

Application Fee