Child Information

Child's First Name*

Child's Last Name*

Hebrew Name

Gender*
 Male Female

Student Status*
 New Student Returning Student

Date of Birth* i.e mm/dd/yyyy

Grade (as of Sep. 2011)*

School*

Street Address

Address Line 2

Zip Code*

Phone* i.e xxx-xxx-xxxx

Child Lives With
 Both Parents Parent 1 Parent 2

Other (please explain)

PARENTS

Parent 1

First Name*

Last Name*

Email*

Work Phone i.e xxx-xxx-xxxx

Cell Phone* i.e xxx-xxx-xxxx

Occupation

Address (Complete if different from student's above)

Street Address

Address Line 2

City

State

Zip / Postal Code

Parent 2

First Name

Last Name

Email

Work Phone i.e xxx-xxx-xxxx

Cell Phone i.e xxx-xxx-xxxx

Occupation

Address (Complete if different from student's above)

Street Address

Address Line 2

City

State

Zip / Postal Code

EMERGENCY CONTACT INFORMATION

First Name*

Last Name*

Relation*

Email

Phone* i.e xxx-xxx-xxxx

STUDENT QUESTIONS

1. Has your child received any formal Jewish education in the past? *

 Yes No

Please write where and for how long.

2. What does Judaism look like in your home? (Do you celebrate Shabbat at home? Other holidays?)

3. What is your child’s relationship to Judaism? (Goes to Jewish camp? Is interested in learning and asking questions about being Jewish?)

4. Does your child have any special learning needs? Please explain below, and please provide any relevant documentation including an IEP.

 Yes No

Please explain.

5. Please list all existing medical conditions of special concern (including allergies to medication and food).

6. Occasionally teachers may take a class on a “Jewish nature walk” or other off-site trips. I give permission for my child to attend off-site trips accompanied by Mishkan Tefila teachers/staff and parental chaperones.

 Yes No

7. I give permission for my child’s photograph to be used in synagogue, school or community publications.

 Yes No

8. Please add any other comments or information.

Signature of Parent
 Yes

Please type in the letters and numbers you see below