New Student Application

Name

This field is for validation purposes and should be left unchanged.

1. FAMILY INFORMATION

Date of Application(Required)

Student Name(Required)

First Middle Last

Legal Name (if different)

First Middle Last

שם בלשון קודש(Required)

First Middle Last

Date of Birth(Required)

Place of Birth(Required)

City State / Province / Region ZIP / Postal Code Country

Grade Applying for(Required)

Applying for School Year(Required)

Languages Spoken(Required)

English

Hebrew

Yiddish

Other

Please Indicate Other Languages(Required)

Student's Home Address(Required)

Street Address City State / Province / Region ZIP / Postal Code Country

Parents' Marital Status(Required)

Legal Guardian(s)(Required)

Click on the "+" sign to add all legal guardians.

Last Name

First Name

Relationship to Student

Whom should we contact to schedule an interview (faher)?

Name

Phone Number

Father/Male Guardian

Father(Required)

Title(Required)

Father/Male Guardian's Title

Name(Required)

Father/Male Guardian's Name

First Middle Last

Legal Name

If different

First Middle Last

Languages Spoken(Required)

English

Hebrew

Yiddish

Other

Please Indicate Other Languages(Required)

Shul(Required)

Home Address(Required)

Address(Required)

If different from student's

Street Address City State / Province / Region ZIP / Postal Code Country

Contact Information(Required)

Home Phone

Cell Phone

Work Phone

Email

Occupation(Required)

Occupation

Employer

Employer's Address

If remarried(Required)

Name of Spouse

Spouse's Work Phone

Mother/Female Guardian

Mother(Required)

Title(Required)

Mother/Female Guardian's Title

Name(Required)

Mother/Female Guardian's Name

First Middle Last

Legal Name

If different

First Middle Last

Languages Spoken(Required)

English

Hebrew

Yiddish

Other

Please Indicate Other Languages(Required)

Maiden Name(Required)

Home Address(Required)

Address

If different from student's

Street Address City State / Province / Region ZIP / Postal Code Country

Contact Information(Required)

Home Phone (if different)

Cell Phone

Work Phone

Email

Occupation(Required)

Occupation

Employer

Employer's Address

If remarried(Required)

Name of Spouse

Spouse's Work Phone

Siblings

Siblings(Required)

You can add as many lines as you need

Name

Age

Yeshiva

Grade

2. ACADEMIC INFORMATION

ALL questions MUST be completed. If question does not apply, please write “n/a” or “none.”

Current School Information(Required)

Current school

Grades attended

Contact Information(Required)

Name and Phone Number

Contact person (Name & Phone Number)

Principal (Name & Phone Number)

Current rebbe (Name & Phone Number)

Previous rebbe (Name & Phone Number)

Previous School Information(Required)

Previous school

Grades attended

Contat person

Position

Phone

Extra-curricular activities, interests, and talents (i.e. music, sports):(Required)

Computer skills:(Required)

Student's communal activities, organizational affiliations and/or chesed activities:(Required)

Parents' communal activities, organizational affiliations and/or chesed activities:(Required)

Special services your child has received or is eligible for (i.e. Academic, Physical, Social, Emotional, Resource Room, P3, related services):(Required)

Testing:(Required)

Does your child have or had any educational or psychological testing? A current or prior IEP (Individual Education Plan)?

Evaluation Dates:(Required)

First time

Last time

Upload a copy of existing and prior IEP(s):(Required)

You can upload multiple files

Drop files here or

Max. file size: 64 MB.

Medical History:(Required)

Medication(s) taken (i.e. carries an epipen, inhaler, syringes)

Medical condition(s)

Doctor's name

Type of doctor

Phone number

Main Contact(Required)

Person Responsible for Finances:(Required)

Name & Phone #(Required)

Student's Challenges(Required)

Please advise us of the student’s current or possible challenges, which may impact the student’s education, including but not limited to physical, psychological, social, or family matters. Please attach all supporting information. All responses are kept and will remain strictly confidential.

Upload supporting information

You can upload multiple files

Drop files here or

Max. file size: 64 MB.

3. Consent and Release of Records

Name of Parent or Legal Guardian filled out the form(Required)

Name of Parent or Legal Guardian

First Last

Signature of Parent or Legal Guardian

4. PHOTO UPLOAD

PDF, JPG, JPEG, PNG

Student's Photo(Required)

Recent passport/portrait photo

Drop files here or

Max. file size: 64 MB.

5. Payment

Please submit the payment of $100.00 to complete the application. The application fee is non-refundable.

Application Fee

Billing Address(Required)

Street Address City State / Province / Region ZIP / Postal Code Country

Credit Card(Required)

American Express

Discover

MasterCard

Visa

Card Number

Expiration Date

Security Code Cardholder Name

Cardholder Signature(Required)

ATTENTION

Please submit this form only ONCE. Due to security settings on many mobile devices and certain browsers, you might receive an ERROR after you submit this form, even though the form was correctly processed on the server side. If that is the case, please take a picture of the error and please share with us. We are aware that a few people are experiencing this error, but we are unable to replicate it on our end. It would help us troubleshoot to have more information about the environment that precipitated the error. Thank you for your help.

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THANK YOU FOR YOUR INTEREST IN MESIVTA SHAAREI ARAZIM.

Application Checklist