Registration Form

Child's Full Name:

First NameLast Name

Hebrew Name:

Address:

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Phone Number:

Area CodePhone Number

E-mail:

Age in September:

Birth Date:

MonthDayYear

Grade Entering:

Public School Attending:

Father's Name:

Hebrew Name:

Business Address:

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Business Phone Number:

Area CodePhone Number

Occupation:

Mother's Name:

Hebrew Name:

Business Address:

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Business Phone Number:

Area CodePhone Number

Occupation:

Synagogue affiliation:

Previous Hebrew Education:

Does your child read basic Hebrew yet?

PoorFairGood

Does your child have any learning difficulties with general studies?

YesNo

If yes, please explain:

Is there any special medical or other information regarding your child, of which the school should be aware?

YesNo

If yes, please explain:

Were there are conversions or adoptions in your family?

YesNo

If yes, please explain:

How did you hear about Shaloh Hebrew School?

If applicable, please give the name of the person who referred you to Shaloh Hebrew School:

I ConsentI DO NOT Consent

Child Information:

Parent Information:

Previous Education:

Referral:

PARENTAL CONSENT

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