Does your child recognize letters of the Aleph- Bet: Yes No

Does your child have any learning difficulties with general studies?

Yes  No

Please explain

What school does your child attend?

Family info

Family name

Parent/ Guardian Name

Hebrew name of parents

Address

City , NJ Zip Phone: Home

Work Cell

Occupation:

E-mail Do you check it often? Yes No

Medical Information

Are there any medical conditions/allergies or pertinent information regarding your child, which we should be aware of?

Child's Doctor's Name:

Doctor's Phone #

Emergency Contact Information

Name

Phone Relationship

Parents Signature

Date

Please do not include my in the school directory

Please do not publish any photographs of my child