Student's Name (Last, First, Middle):


Date of Birth:


Address: (Street, City, Zip)


Phone:


Father's Name & Business Phone:


Mother's Name & Business Phone:


Grandparent(s) Names:


Grandparent(s) Address: (Street, City, Zip)


Present Grade:


Admission to Grade:


Name of Day School/Public School:


Address of Parent (If different from child)


Synagogue Affiliation


Give Name, Age, and School of Brothers and Sisters


Parent's agree to pay tuition of for school
year of enrollment. No credit or allowance will be made for absence
or withdrawal of the child, regardless of the reason for such absence
of withdrawal.

EMERGENCY TREATMENT: If at any time due to accident or illness emergency medical treatment is necessary, parents authorize the
school to obtain required care from local physician, hospital or
emergency medical service. Parents will be notified as soon as
possible under circumstances.



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