"*" indicates required fields Step 1 of 9 11% Ohr Zahava Student Registration From This is a child care agreement between Ohr Zahava SchoolStudent's Demographic InformationChild's Full Legal NameFor the care of the following child First Middle Last Hebrew Name* Nickname ( Preferred Name) Jewish Status*Born JewishConvertNot JewishConversion DocumentationPlease upload supporting documentation Drop files here or Select files Max. file size: 32 MB, Max. files: 3. Child Date of Birth* MM slash DD slash YYYY Gender* Male Female Age*Please enter a number from 3 to 18.Home Address Street Address City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Synagogue Affiliation Relationship to Child*Relationship to the person filling out the form? Mother Father Legal Guardian Parent's Marital Status*MarriedDivorcedCourt Order DocumentationPlease upload supporting documentation Drop files here or Select files Max. file size: 32 MB, Max. files: 3. Custodial Information*Please describe the court custodial agreement. Who is the primary custodian, is it shared custody . Or does one parent have full custody. Parent's InformationFather's Name* Prefix Mr.Mrs.MissMs.Dr.Prof.Rev. First Middle Last Father's Phone*Father's Email* father is Primary Point of Contact Is the Primary Point of Contact? Father's Profession* Father's Employer* Father's Affiliation* Born Jewish Not Jewish Converted to Judaism Rabbi that helped with Conversion* Home Address Street Address City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Mother's Name Prefix Mr.Mrs.MissMs.Dr.Prof.Rev. First Middle Last Mother's Phone*Mother's Email* Mother is Primary Point of Contact Is the Primary Point of Contact? Mother's Profession* Mother's Employer* Mother's Affiliation* Born Jewish Not Jewish Converted to Judaism Rabbi that helped with Conversion* Home Address Street Address City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Does the student have another legal guardian? Yes No Legal Custodian's Name Prefix Mr.Mrs.MissMs.Dr.Prof.Rev. First Middle Last Legal Custodian's Phone*Legal Custodian's Email legal custodian is Primary Point of Contact Is the Primary Point of Contact? Legal Custodian's Profession Legal Custodian's Employer Legal Custodian's Affiliation Born Jewish Not Jewish Converted to Judaism Rabbi that helped with Conversion Home Address Street Address City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Emergency Contact InfoEmergency Contact*In the event parents cannot be reached First Last Emergency Contact Phone*Emergency Contact Relationship to child* All About Your ChildPlease upload a picture of your childMax. file size: 32 MB.Primary language spoken at home? Other languages your child is routinely exposed to? Has your child been in school before? Yes No Last Grade Completed*Please enter a number from 1 to 12.Name of School School Address and Contact NumberDate Schooling at Former School Started: MM slash DD slash YYYY Date Schooling at Former School Ended: MM slash DD slash YYYY Reason Schooling was terminatedHousehold Members (Include age, gender and current school)* Dietary InformationDoes your child have a special diet? Yes No Are there any foods that should not be served to your child? Please list the food and the reasonYour child's favorite foods Your child's least favorite foods Health InformationDoes your child have known allergies?* YES NO Known allergies Food or Medical AllergiesPlease describe the nature of the allergies and how they are treated.Medical History: (ex. Surgeries, allergies and communicable diseases child has had, etcAre there any extenuating circumstances that may affect your child that the school should know about? (pregnancy, new sibling, death or illness of another family member, etc?)Child's Special Care Requirements* Environmental Allergies Food Intolerances Existing Illness Previous Serious Illness Limitations or restrictions on child's activities Necessary accommodations or modifications Adaptive equipment Symptoms or indications of complications Medications prescribed for continuous long-term use None Explain any requirements from above:Does your child have any special educational needs or diagnoses?Please upload any IEPMax. file size: 32 MB.Child's Doctor First Last Suffix Doctor's Phone NumberDoctor's Address Clinic Name City State / Province / Region ZIP / Postal Code MedicationsPharmacyPharmacy Name & Address MedicationsDoes your child take any medications on a regular basis? YES NO Does your child take any medications on a regular basis?List all prescribed and over the counter medicationsMedicationFrequencyPrescribed? YES or NO Add Remove Permission to administer Over the Counter MedicationI give my permission to use the following over-the-counter or external preparations as needed according to the directions for use on the container. Note: If the directions for use are not specific on the container, (such as Tylenol for a child under the age of 2), I will need a physician's note with the appropriate dosage** I agree I do not agree MedicationsName of MedicationDosage PermittedTimes of Dosage Add RemovePermission To Administer Prescription MedicationI give my permission to use the following prescription medication* I agree I do not agree MedicationsClick on the + to add more medicationsPrescribing PhysicianName of MedicationDosageTimes of Dosage Add RemoveAny special instructions? Transportation PermissionI/We give permission for my/our child To leave Ohr Zahava in the company of:*List the names of the people that have permission to take your child out of school This signed statement includes emergency transport, field trips, errands, etc. at the discretion of the child care provider. Should travel take place by vehicle, the driver shall hold a current driver's license, and the vehicle will be registered and insured according to state law I agreeParent's Signature How did you hear about Ohr Zahava?Disclaimer*Please read the following disclaimer carefully before submitting the application form for Ohr Zahava Private School. By submitting the application, you acknowledge and accept the terms outlined below. Evaluation and Acceptance: Ohr Zahava Private School evaluates each application on a case-by-case basis. While we strive to provide an inclusive and enriching educational environment, submission of the application form does not guarantee acceptance of the child into our school. The admission decision is based on various factors, including but not limited to the availability of seats, academic readiness, and compatibility with the school's mission and values. Admission Criteria: Our admission process considers a range of factors such as academic records, character references, assessments, interviews, and space availability. Ohr Zahava Private School reserves the right to determine the suitability of applicants based on these criteria. Non-Guarantee of Acceptance: Please note that we do not guarantee the acceptance of any child applying to Ohr Zahava Private School. Each application is assessed individually, and acceptance is contingent upon meeting the school's admission requirements and the availability of space in the desired grade level. Confidentiality of Information: All information provided in the application form and accompanying documents will be treated with strict confidentiality. However, please be aware that Ohr Zahava Private School may share relevant application information with authorized personnel involved in the admissions process. Application Withdrawal: If you choose to withdraw your child's application at any point during the process, please notify the admissions office promptly. Communication of Decision: Once the admissions committee has reached a decision regarding your child's application, you will be notified in a timely manner. Please understand that the timing of communication may vary based on the volume of applications and the evaluation process. By submitting the application form, you agree to abide by the terms and conditions stated in this disclaimer. Should you have any questions or require further clarification regarding the application process, please contact our admissions office for assistance. I agree to abide by the terms and conditions stated in this disclaimer.Signature* Δ
