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Application for Admission
General Information
Student Name (Last, First, M.I.)
*
Student Preferred Name
*
Student Hebrew Name
*
Date of Birth
*
Grade Applying For
*
Student Sex
*
Male
Female
Home Address (Street, City, State, Zip)
*
Home Phone
*
Parent Information
Father's Prefix
*
Mr.
Dr.
Prof.
Rabbi
Father's Name (Last, First)
*
Father's Hebrew Name
*
Address (If different from the student)
Cell Phone
*
Work Phone
Email Address
*
Occupation
*
Business Address
Mother's Prefix
*
Ms.
Mrs.
Dr.
Prof.
Mother's Name (Last, First)
*
Mother's Hebrew Name
*
Address (If different from the student)
Cell Phone
*
Work Phone
Email Address
*
Occupation
*
Business Address
Marital Status of Parents
*
Married
Separated
Divorced
Widowed
Child Lives With
*
Both Parents
Mother
Father
Joint Custody
Legal Guardian
Name(s) of stepparent(s)/guardian(s)
Are both parents biological parents?
*
Yes
No
Please explain.
*
Are both parents Jewish by birth?
*
Yes
No
Please explain.
*
Please upload a copy of conversion documents.
Synagogue Affiliation
*
Sibling Information
How many siblings does the applicant have?
*
0
1
2
3
4
5
Please list full name(s), birthdate(s) and school(s) currently attending of all siblings.
*
Applicant Information
Current School
*
Current Grade
*
Is the applicant currently in the grade appropriate for his/her age?
*
Yes
No
Explain.
*
School Address (Street, City, State, Zip)
*
School District
*
Has the applicant undergone any visual, speech, IQ, learning or behavior assessment?
*
Yes
No
Explain.
*
Please upload applicable assessment.
Has the applicant ever been subject to major discipline problems at any school?
*
Yes
No
Explain.
*
Has the applicant been under continuing care for any physical, emotional or learning difficulty?
*
Yes
No
Explain.
*
I/We are prepared to get academic and non-academic assistance as needed if recommended by the school.
*
Yes
No
Conclusion and Signature
Is there anything else you would like us to know about your child/family that was not asked above?
How did you find out about Epstein Hebrew Academy? Please check all that apply.
*
Friend
Colleague
Alumni
Synagogue
Current Family
Jewish Light Magazine
EHA's Facebook
EHA's Daf Kesher
Internet Search
What other schools are you considering at this time?
Will you be applying for financial aid?
*
Yes
No
By signing this application, you certify that the information provided above is complete and accurate to the full extent of your knowledge.
Parent/Guardian Signature
*
clear
Date
*
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