Returning Student Registration CHILD'S INFOChild's Name* First and Middle Last Child's Hebrew Name* Date of Birth* MM slash DD slash YYYY Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country PARENT'S INFOMother's InfoTitle*Mrs.Dr.Full Name* First Last Hebrew Name* Date of Birth* MM slash DD slash YYYY Cell Number*Work Number*Occupation and Place of Employment* Email* Father's InfoTitle*Mr.Dr.Full Name* First Last Hebrew Name* Date of Birth* MM slash DD slash YYYY Cell Phone*Work Phone*Occupation and Place of Employment* Email* Child's Medical InformationDoes your child have any medical conditions?* Yes No Please Specify Does your child have any allergies?* Yes No Please Specify Has your child ever been evaluated for developmental delays or has an evaluation been recommended in the past?* Yes No Please Elaborate Is your child taking any medications?* Yes No Please Specify Pediatrician Name* Pediatrician's Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Pediatrician's Phone Number*Name of Insurance Policy* Policy Number* In case of a medical emergency requiring immediate emergency care, I hereby give permission to treat and transport my child by ambulance, to the nearest hospital necessary. I give permission for my child's medical information to be shared with medical staff.* Parent’s SignatureCell Phone Number*PickupPersons authorized to pick up child* Additional InfoDoes your child have special food or eating instructions? Are there are any specific napping or sleeping instructions?* Is your child toilet trained? If in progress, please explain* Describe assistance needed and words used Does your child nap?* Yes No If yes, what time? My child wakes up in the morning at (specify time) and goes to sleep at (specify time) Does your child have any fears?* What methods of behavioral discipline are used in your home? Is there any additional information, such as child's communication, discipline, or family circumstances that you feel we should know about? Do you think your child will display separation anxiety on his/her first day at preschool?* Yes No Do any parent or close relatives have any special talent to share with our students? As you enroll your child in our program, please list the skills your child has mastered: EMERGENCY CONTACTSPlease indicate telephone numbers where you and another authorized person can be contacted in case of emergency:Parent 1 Name* First Last PhoneParent 2 Name First Last PhoneAdditional Authorized Person First Last PhoneRelationship to Child EMERGENCY CONSENTIn case of emergency, I authorize the staff to provide any medical care or first aid deemed necessary for my child. In case of emergency, I hereby authorize transfer of care to my child’s physician or local hospital and health records transfer. Parent's Signature* Date* MM slash DD slash YYYY SchedulePlease note that there will be a fee for a schedule change. An additional $75 will be charged to anyone who changes their child’s schedule before the first week of school, and a $150 fee will be charged for a schedule change after the first week of school.Full Day: 9:00 AM – 3:00 PM or Core Program : 9:00 AM – 12:30 PM*Select your choice of full day schedule 9:00 AM – 3:00 PM, or Core Program 9:00 AM – 12:30 PM 5 full days per week (M-F) 9:00 AM – 3:00 PM 5 half days per week (M-F) 9:00 AM – 12:30 PM 3 full days per week (M,W,F) 9:00 AM – 3:00 PM 3 half days per week (M,W,F) 9:00 AM – 12:30 PM 2 full days per week (Tu,Th) 9:00 AM – 3:00 PM 2 half days per week (Tu,Th) 9:00 AM – 12:30 PM Please review your application before submitting* I have reviewed the application, and hereby register my child for the 2023-2024 school year.I have reviewed the application and guidelines. All the information I have provided on this form is true. I hereby register my child for the 2023-2024 school year. I also understand that once my child is accepted and contracts are signed, there are no refunds under any circumstances.Signature of Parent* Parent’s Signature Date MM slash DD slash YYYY Non-Refundable Registration Fee* Price: Deposit*Non refundable deposit $175 (required to secure your child’s spot. Will be credited towards first month’s tuition). Price: Credit Card American ExpressDiscoverMasterCardVisaSupported Credit Cards: American Express, Discover, MasterCard, Visa Card Number Month010203040506070809101112 Year20232024202520262027202820292030203120322033203420352036203720382039204020412042 Expiration Date Security Code Cardholder Name Coupon Total $0.00 2020-06-19
